Provision of Assistive Technology in the Nordic Countries

1 Introduction

Nordic cooperation on assistive technology

Publicly financed systems for the provision of assistive technology to people with disabilities are among the cornerstones of policy on disabilities in the Nordic countries. These systems – which are unique in the international arena – are based on the principle whereby society must compensate for disability as far as possible by means of jointly financed undertakings.

The Nordic cooperation in the field of assistive technology goes back a long way. This was one of the first areas for cooperation when the cooperation relating to policy on disabilities began in 1977 under the Nordic Council of Ministers. The close cooperation of the Nordic countries has had an enormous part to play in ensuring that the national systems for the provision of assistive technology currently share so many features.

The Nordic cooperation on assistive technology, which was developed by the social ministries from the beginning, has for many years been based on close cooperation between the national authorities for the provision of assistive technology in the Nordic countries and the like. The partners involved are the Danish Centre for Technical Aids for Rehabilitation and Education, STAKES (the National Research and Development Centre for Welfare and Health) in Finland, the State Social Security Institute in Iceland, the National Insurance Administration in Norway and the Swedish Handicap Institute. This partnership involves – among other things – testing, purchasing issues and information. The managers of the national authorities for the provision of assistive technology in the Nordic countries and their equivalents are also part of the steering committee for the Nordic Development Centre for Rehabilitation Technology (NUH) in Helsinki, a daughter institution of the Nordic Cooperation on Disability (NSH).

The Nordic countries’ systems for the provision of assistive technology to people with disabilities are characterised by far-reaching decentralisation and a lot of different parties at local, regional and national level. Public expenditure on such activities is extensive – running into billions – and so there are stringent demands for professionalism and efficiency for these activities. Over the years, the Nordic cooperation has been of great significance to the development of national assistive technology activities of top quality.

The need for Nordic cooperation in the field of assistive technology has been intensified by the European integration development in progress since the early 1990s. These countries have grasped the challenge with both hands and consciously used the Nordic cooperation as a platform to exert their collective influence within the European cooperation, both in European research programmes and in the field of assistive technology standardisation.

The Nordic assistive technology cooperation is continuing its development. One overall objective for the cooperation is to intensify the Nordic countries’ chances of retaining and further developing their traditionally high quality requirements in the field of assistive technology, and to reinforce their position as role models in their use of new technology to compensate for disabilities.

National systems for the provision of assistive technology

The Nordic countries’systems for the provision of assistive technology share many features, as has already been suggested. The most important feature of all this is that these activities are financed using public funds. However, in this respect the models and distribution of costs vary between local, regional and national level. Only Norway provides assistive technology funded entirely by the State. Responsibility for costs is also divided over a variety of sectors of society (such as education and work) to differing extents.

The systems are complex and assume coordination between lots of different parties. The degree of complexity has been a great challenge to us when preparing the descriptions in this publication relating to the Nordic countries’systems for the provision of assistive technology. Our aim has been to make the descriptions as comparable with one another as is humanly possible.

The Nordic countries’systems for the provision of assistive technology are, in many respects, exemplary. However, the situation is not without its problems. To conclude this introduction, it may be expedient to point out a few current problems which the countries have in common and which represent challenges for future national development work in the field of assistive technology.

Developments in the field of information and communications technology have moved the goalposts in the field of assistive technology. Developments have paved the way for new means of compensating for disabilities, but they have also fuelled the debate on where the boundaries lie between “assistive technology” and common consumer products that everyone needs, or at least wants. This debate is not new: many years ago, it dealt with the issue of dishwashers. Now the debate revolves around computers, mobile telephones, video telephones and smart house technology, among other things.

The debate on where the boundaries lie between assistive devices for people with disabilities and general consumer products has also brought to the fore the issue of what people pay for themselves/own themselves. The issue of what people pay for themselves is not new, either: this matter was previously called to the fore from other perspectives. A third challenge, which has intensified on account of developments in the field of information and communications technology, is the need for coordination over sector and administrative boundaries so that the overall activity is as effective as possible from the point of view of society but also, above all, from the point of view of the individual.
The challenge faced by all the Nordic countries involves adapting assistive technology activities to meet new criteria, while still maintaining the principles of public responsibility and actual user influence. The work of the Nordic cooperation and exchange of experience continues to be important.

Finn Petrén

2 Provision of assistive technology in Denmark

Policy and principles for the provision system

Danish policy on disabilities, and thus also legislation in the field of assistive technology, is based on three main principles: the solidarity principle, the compensation principle and the sector responsibility principle.

The solidarity principle means that everyone has responsibility for individuals, and that when the need arises, the necessary activities are implemented with a view to safeguarding the future existence of the people concerned. The solidarity principle means that the necessary activities for people with disabilities are widely financed by the public sector; that is to say, by means of taxation.

The compensation principle means that people with disabilities are compensated for the consequences of their disabilities. Some of this “compensation” takes place by ensuring that what society has to offer is made available to people with disabilities, as well as by providing various special activities such as assistive devices, adapting their homes, covering additional expenses, supporting their employment, etc. When it comes to allocation, it is emphasised that disabled people themselves must pay the element of the costs equivalent to the fees they would have had to pay in any case if they had not been disabled. On the other hand, people with disabilities should not have to cover the additional expenditure resulting from their disabilities.

The sector responsibility principle provides a starting point for defining the context in which activities belong. Sector responsibility means that the public sector offering activities, services or products is responsible for ensuring that the activity, service or product in question is accessible to people with disabilities. Thus work in the field of disabilities is not simply a matter for the Ministry of Social Affairs. Instead, it also applies to a number of other ministries such as the Ministry of Education and Research, the Ministry of Labour, the Ministry of Culture, the Ministry of Housing and Building, the Ministry of Health, etc. In the field of assistive technology, this means that responsibility for grants for assistive technology is placed with the authorities where the need arises.

Rules on support for assistive technology

A central law in the field of assistive technology is the Social Services Act, also known as the Services Act. This law is used in the case of grants for a range of different activities compensating for impairments, such as grants for assistive devices and consumer goods in the home (Services Act, §§ 97 and 98), grants for home adaptation (Services Act, § 102), grants to cover necessary additional expenditure with regard to care (Services Act, §§ 28 and 84) and grants to help people buy cars (Services Act, § 99).

As mentioned, the sector responsibility principle applies in general to policy on disabilities, and as a consequence of this, responsibility for grants for assistive technology is not merely a social issue regulated by means of the Services Act, but rests with a range of different authorities and included in a large number of laws regulating the various fields, such as the Act on active social policy (grants for assistive technology for use in business), the Treatment Circular (grants for assistive technology for temporary use/treatment), the Primary and Lower Secondary Schools Act (grants for assistive technology for use in primary and lower secondary schools and lessons in the home), the Upper Secondary School Act, the Act on technical colleges, the Act on training opportunities courses, etc. (grants for assistive technology for use during the courses in question) and the SPS Act (grants for assistive technology for use in further education).

The individual acts, which include rules on grants for assistive technology, set various criteria for the allocation of assistive devices and other aid measures. All of these acts have in common the fact that cases are always decided upon by means of an assessment specific to the individual in question. These are framework acts, so there is plenty of scope for individual municipalities and county councils to set their own service levels; within the scope of the legislation, of course. Cases can also be passed on to another authority so as to ensure that citizens are dealt with uniformly and that their rights are safeguarded.

Assistive devices for home use

Within the scope of the Services Act, municipalities are responsible for providing grants for assistive devices and consumer goods for people with long-term physical or mental disabilities when an assistive device:

• could relieve the long-term effects of the disability to a great extent
• could facilitate day-to-day home life to a great extent, or
• is necessary to allow the person in question to do a job.

County councils provide grants for:

1. optical assistive devices and low vision aids for people with long-term impaired vision or medically defined, long-term eye problems
2. prosthetic arms and legs
3. hearing aids
4. special IT-based assistive devices and assistive devices to support these
5. cars for physically disabled people.

County councils are responsible for providing grants for specific fields of assistive technology because individual municipalities have so few direct cases in the fields in question that there is no reason for them to acquire the requisite expertise. On the other hand, individual county councils have the opportunity to acquire enough cases to develop expertise in the field.

In Denmark, there is no complete list of the assistive devices that can be provided, or a list of products considered to be assistive devices. However, amendment of the law in June 1998 resulted in the division of assistive devices into three groups: general equipment, consumer goods of particular value to users with disabilities, and assistive devices.

General equipment includes products which anyone requiring them can acquire, such as ordinary beds, TVs, mattresses, chairs, telephones, etc. No grants are given for these. Consumer goods are products manufactured and sold widely in anticipation of ordinary use among the general populace, but which are of special value to people with disabilities (e.g. computers for people unable to talk). 50 per cent grants are awarded for these types of assistive devices, which then become the property of the user. Finally, we have the assistive devices category. These are regarded as products manufactured with a view to helping to alleviate the effects of physical or mental disability.

Grants for personal assistive devices are awarded to people living in institutions according to the same rules that apply to people living in their own homes. Assistive devices and basic equipment for collective use by people living in special accommodation, residential institutions or similar must be placed at the disposal of the institution in question.

Assistive devices are lent out free of charge for as long as they are required. Criteria for allocation and checking procedures are the same for both consumer goods and assistive devices.

Assistive devices for use in education and training

The rules on grants for assistive devices in the field of education and training, as mentioned, are included in the relevant laws, but as a rule the assistive device in question must be necessary for the person in question to take part in the education/training. By way of example, primary and lower secondary schools, according to the Regulation on special education and other special teaching aid, are responsible for providing, to the requisite extent, special educational materials and assistive devices for staff required in connection with educating students if their development requires special consideration or support. Users do not have to make any payments for assistive devices for use in education or training – nor when the assistive device in question is a computer – and such assistive devices are provided for as long as the person in question needs them and remains in education/training.

Students at private schools have the option of applying for special teaching aid in line with students in primary and lower secondary schools, including assistive devices for staff.

Educational assistive devices can, as part of special teaching aid, be provided for children who have not started school, cf. the Primary and Lower Secondary Schools Act, para. 4. 1.

Assistive devices for use at work

There are various options as regards support for assistive devices for people with disabilities who are either about to get a job or are already working. As a starting point, it is stipulated in the Act on active social policy (Active Act, § 78), that the municipality is obliged to provide grants for tools and equipment (including assistive devices) when this aid is crucial for the person in question to get or keep a job. The tool or equipment in question must compensate at work for that person’s disability. As well as municipalities, job centres can also provide support for assistive devices for disabled people who are members of an unemployment fund. Where the boundary lies between municipalities’ and job centres’ areas of responsibility is not entirely clear.

People undergoing rehabilitation also have the option of acquiring support for assistive devices from the municipality in accordance with the Act on active social policy (Active Act, § 63).

Assistive devices for treatment and training

The area of responsibility of the hospital service, as expressed in the Treatment Circular, includes providing assistive devices which the person in question requires for only a short period as that person’s condition is not long-term. These assistive devices are regarded as temporary assistive devices or “treatment tools” and are loaned out by the hospital.

Support for assistive devices in general

Besides the above, there are also a number of rules relating to the allocation of assistive devices in other fields, such as for use at work, in spare-time education, etc., or for specific target groups; such as text telephones for deaf people, hearing impaired people and people with speech impairments, TV and video programmes in sign language for deaf people, publications on audio tape and in Braille for blind people and people with sight problems, etc.

Administrative rules

As well as the legislation stipulating which groups of people are entitled to assistive devices, and in accordance with which conditions, there is also legislation which relates to the rules for administration of cases. The Act on Public Security and Administration relates to – among other things – ensuring citizens’ public security when the social authorities deal with cases, and to basic principles for the administration of social cases.

In the guidelines to this legislation, it states, among other things, that the authorities must arrange the assistance as a coherent offer, sit as far as is possible, on the basis of a joint assessment of a citizen’suation, and that during the process, it is necessary to assess whether the objectives have been attained and whether adjustment of the measures is necessary, and that what action is taken must be made clear in the authorities’ written case notes. Furthermore, it states that professional assessments must be produced and assessed in cooperation with the citizen in question with a view to finding a correlation between the citizen’s own lifestyle and self-knowledge and the professional assessment of the information available.

In other words, all factors must be reported in the case notes. Documenting the progress of cases is compulsory and is of significance as regards citizens’ right of access to documents as described in the same act.

Appeals and complaints

If a citizen is unhappy with a decision relating to the allocation of assistive devices or home adaptation in accordance with the Services Act, a complaint may be lodged against the decision with the Social Services Council which every county council has. Here, the case can be heard by another authority. This decision has legal effect, meaning that the decision made must be adhered to by the county council, municipality and citizen in question.

There is also another complaints procedure which is instigated via the Social Appeals Board, which is the central national appeals board for social issues. If any of the parties involved is not satisfied with the regional decision, the case can be brought before the Social Appeals Board. Once this has been done, the Social Appeals Board decides unilaterally whether it wishes to take up the case to assess it in principle and make a decision. The Social Appeals Board publishes summaries of these decisions, creating a subsequent foundation for future case law in the field throughout the entire country.

Citizens also have the option of making complaints about decisions made in accordance with legislation other than the Services Act. In some cases, complaints can be made to the municipal council in question, while in other cases a special complaints board is set up. As far as education is concerned, there is a special Complaints Board for Extensive Special Education which deals with appeals relating to extensive special education.

Organisation and distribution of responsibilities

The sector responsibility principle indicates that responsibility for the allocation of assistive devices and for making them more widely available rests firmly with various sectors and institutions. This means that a number of different sectors have had to build up parallel provision systems in the field of social issues, schools, vocational training and the working environment sector, for example.

Provision system within the area of responsibility indicated by the Services Act

According to the Services Act, municipalities are responsible for giving their citizens advice and support to help prevent social problems. The same is also true for advice on and support for assistive devices and consumer goods. The municipalities are the bodies which deal with applications for assistive devices, except for when the specific fields of assistive technology covered by the county council are involved. Every municipality purchases assistive devices and runs its own assistive technology warehouses offering recycled assistive devices. However, there is a tendency for more and more municipalities to lease their assistive devices from private suppliers which have set up warehousing functions, or for a number of municipalities to join forces and enter into collective procurement contracts and warehousing functions.

There are 274 municipalities in Denmark, and this means that the structure is very decentralised, with pronounced municipal self-rule. Large municipalities are divided into a number of area offices, each of which has its own case managers in the field of assistive technology. This form of organisation of the provision of assistive technology demands high levels of knowledge, expertise and ongoing training.

In addition to dealing with cases belonging to their area, the county councils (14 of them in total, as well as two large municipalities with county council status) also have to provide advice to municipal case managers who need specialist knowledge. The municipal case managers have the opportunity to seek expert assistance from county councils’ assistive technology centres in order to resolve specific issues. Many assistive technology centres also offer courses for municipal case managers in the field of assistive technology. The county councils have a variety of structures for dealing with these matters. However, they do all have assistive technology centres (of varying sizes): one has been privatised, and another has a tradition of organising all municipalities’ assistive device warehouses for the entire county. Thus all county councils deal with these issues in their own individual ways.

Users have the option of contacting the assistive technology centre in the county where they live for advice and guidance on all types of assistive devices.

Financing

In general, assistive devices and other services provided to compensate for impairments are financed by the public sector through taxes. However, the exceptions described previously apply: for example, users themselves have to pay 50 per cent of the price of consumer goods, and support for specially adapted cars is provided in the form of interest-free loans which must be paid back. Likewise, there is a general administration principle which states that the body granting the funding is also obliged to make the payment.

In the case of assistive devices and consumer goods for people aged under 67, municipalities and county councils pay 50 per cent of the cost each, while on the other hand municipalities pay the full amount for assistive devices allocated to people aged 67 or above. However, when the Services Act came into force in 1998, county councils – as mentioned previously – were given authorisation to allocate assistive devices and full financial responsibility for optical assistive devices, prosthetic arms and legs and hearing aids, as well as special ICT-based assistive devices.

Since then, there has been increasing pressure from user organisations to allow users themselves to select their own assistive devices and suppliers of assistive devices. This has meant that as far as assistive devices worn on the body (breast prostheses, stoma products, orthopaedic shoes, etc.) are concerned, users can opt to receive a grant in cash and then select their own supplier. However, it must be stated that this grant includes a requirement specification for the assistive device in question. This ensures that the user receives guidance and the authority granting the funding is certain of the function and quality of the assistive device in question. When contracts are drawn up between a municipality/county council and suppliers (supplier contracts), user representatives must be involved: this is a legal requirement.

As far as the operation of individual assistive devices is concerned, there is a general tendency for users themselves to pay more and more, such as paying for their own batteries for electric wheelchairs.

The authority granting the funding is the entity which purchases and owns the assistive device in question. Consequently, all municipalities and county councils have their own assistive technology warehouses (with a few exceptions as noted above). There is no central, national purchasing function or central ownership of assistive devices. The National and Municipal Purchasing Service is currently working with collective procurement arrangements/framework agreements in selected fields of assistive technology.

Rejecting an application for an assistive device on the basis that the budget has been exceeded is not permitted.

Net operating expenses re. adults with impaired physical or intellectual function, DKK millions. PL-2002 (assistive devices, etc.):

Source: Statistics Denmark, The social statement of resources

Assistive devices outside of the auspices of the Services Act are also financed by the public sector – but via other budgets.

Assistive devices for use in primary and lower secondary schools are financed by the municipal educational system. The school authorities are responsible for assessing requirements and allocating the necessary assistive devices for use in the classroom. If students have more extensive requirements as regards support, the county council helps to finance the expenditure. If, for example, a student has severe problems with reading and writing (dyslexia), it is the responsibility of the school authorities to assess that student’s requirement and place the necessary assistive devices – such as a computer with synthesized speech and the relevant software – at his or her disposal. The reverse is true for the financing of assistive devices for use in further and higher education, for example: these are financed via a central fund at the Ministry of Education’s State Education Fund board. A set amount is allocated each year for this purpose. The costs for assistive devices for temporary use/treatment which are provided by the hospital are met in most cases by the county councils.

Central support functions

The municipalities are responsible for providing advice and guidance in the entire social field.

The county councils are obliged to provide advice and guidance to both users and municipal case managers in cases where specialist knowledge is required. The obligations of the county councils to provide advice in the field of assistive technology are dealt with via the assistive technology centres.

To supplement the assistive technology centres, most of the county councils have set up special Technology and Communication Centres (to provide advice on technological assistive devices), low vision centres (to provide advice on low vision aids) and hearing institutes (to provide advice on hearing aids).

The Danish Centre for Technical Aids for Rehabilitation and Education is a nationwide knowledge centre which develops and provides knowledge on assistive devices for rehabilitation and education. The Centre is run by the county councils. The Centre maintains the national database of assistive devices on the Danish market. This assistive device base is available free of charge from the Centre’s website. Municipalities and county councils use data from the database for their own management of the field of assistive technology with regard to casework, inventory control, logistics, statistics, etc. In this respect, the Centre participates in national, Nordic and international partnerships with various other bodies active in the field. In addition, the Centre also takes part in testing and standardisation, thereby helping to ensure that only good, safe assistive devices find their way onto the Danish market.

The Danish Centre for Accessibility is another nationwide knowledge centre under the auspices of the National Agency for Enterprise and Housing. The primary task of the centre is to initiate and implement activities which serve to build up and present knowledge on accessibility for people with special needs.

Likewise, the Institute for the Blind and Visually Impaired is a national institution run by the county councils. The institute’s tasks include providing advice and guidance on assistive devices for blind and visually impaired people, and it also runs a special assistive technology centre for this target group.

The Social Appeals Board, which is the central national appeals board for social issues, has taken on more and more importance in the field of assistive technology. Amendment of the law in June 1998 gave the Social Appeals Board a practice-coordinating role. It has to ensure that all citizens are treated alike, no matter where they live in Denmark and in spite of the extensive municipal and county council self-rule. The Social Appeals Board practises this by publishing its decisions on an ongoing basis and taking the initiative to implement investigations in which it clarifies casework in specific fields and writes concluding articles.

There are a number of publicly financed knowledge centres in addition to those outlined above, each of which is aimed at specific groups of disabled people. These knowledge centres are all extremely important in their own respective fields.

3 Provision of assistive technology in Finland

Policy and principles for the provision system

Over the last 15 years, Finland has undergone a major change; from centrally controlled administration to decentralised administration. The autonomy of municipalities has increased considerably. The State helps to finance the municipalities’ extensive statutory activities, but the municipalities themselves decide on how to organise services for members of their municipalities.

In 2000, STAKES (the National Research and Development Centre for Welfare and Health) implemented an investigation in which access to assistive devices for medical rehabilitation at health centres and central hospitals was scrutinised. The responses showed that there is great variation in how assistive devices are allocated. 68 per cent of health centres and 83 per cent of central hospitals stated that they limit the allocation of assistive devices on the basis of certain criteria. As the term “assistive device” is not without ambiguity, various municipalities have been able to interpret the law in a variety of ways.

Finland’s policy on disabilities is based on the Nordic welfare model. Legislation obliges municipalities to arrange welfare services and health care for their citizens. The aim is to safeguard the services required by citizens in municipalities, regardless of their financial and social position. Essentially, this is based on a model involving services funded by tax revenue and supplemented by private services and civil organisation activities.

As the rehabilitation system is complex, a law has been passed on rehabilitation cooperation. This law obliges the welfare services and health care authorities, labour and education authorities and the Social Insurance Institution of Finland to work together on coordinating rehabilitation measures. These authorities also have to cooperate with other service systems.

Rules on support for assistive technology

Assistive devices for medical rehabilitation

Municipalities or associations of local authorities must ensure that medical rehabilitation services are arranged with regard to content and scope so that they meet the need for rehabilitation within the municipality or the area covered by the association of local authorities in question. Medical rehabilitation services include assistive technology services, which involve assessing and determining the need for assistive devices, allocating assistive devices along with rights of ownership or use, training on and following up the use of assistive devices, and maintenance of these devices. (Public Health Act, 66/1972 and Act on specialised medical care, 1062/1989)

Assistive devices for medical rehabilitation include equipment, devices or similar which are designed to counter disabilities verified on medical grounds and which disabled people need in order to manage their day-to-day tasks. Assistive devices also include care equipment and exercise equipment required for rehabilitation purposes. Personal assistive devices for medical rehabilitation which are required for school and in other situations (Regulation on Medical Rehabilitation, 1015/1991) are provided for disabled students at primary and lower secondary school or upper secondary school (under the age of 17).

Assistive devices are loaned out as a means of medical rehabilitation. Assistive devices which cannot be reused remain the property of the recipient.

Assistive devices for medical rehabilitation are free of charge (Act on client fees in the field of welfare services and health care, 734/1992).

Responsible authorities: municipal health and medical services, special care.

Equipment, household machines, devices and adaptations to accommodation

Disabled people receive reimbursement – either complete or partial, depending on what they need as a result of their disability or illness – to cover costs arising for the acquisition of equipment, household machines and devices which they need in order to carry out their day-to-day tasks.

Municipalities must reimburse severely disabled people for reasonable costs for adaptations to their homes and for acquiring assistive devices installed at home if purchasing these adaptations and devices is necessary – as a result of the impairments or illnesses in question – for such disabled people to function in their day-to-day lives if they do not require ongoing institutional care.

Assistive devices which belong in the home and for which grants are available include hoists, alarms or other equivalent devices that are permanently installed in the home. Municipalities may also place devices which belong in the home at the disposal of severely disabled people (Act on service and support due to disability, 380/1987).

Responsible authorities: municipal welfare services.

Assistive devices for vocational rehabilitation for severely disabled people

The Social Insurance Institution of Finland (KELA) is a social insurance institution owned by society. It is obliged, for the purposes of vocational rehabilitation, to arrange expensive or demanding assistive devices, in order to enhance or maintain the abilities of severely disabled people to work and earn their living.

“Expensive and demanding assistive devices” refers to assistive devices requiring a special technical level. These are provided on an individual basis, taking into account the applicant's disability. Vocational rehabilitation also includes establishing the need for assistive devices and testing their suitability, as well as training the client to use them, checking their use and arranging the requisite servicing.

Severely disabled students at upper secondary school or in classes 7-10 of comprehensive school are entitled to the assistive devices required for their studies (such as computers and low vision aids), on the condition that these are specified in a special vocational training plan which has been approved in accordance with the individual rehabilitation plan which KELA assumes has been drawn up (Act on rehabilitation arranged by the Social Insurance Institution of Finland, 610/1991).

Responsible authorities: the Social Insurance Institution of Finland (KELA).

Assistive devices for use in schools and classrooms

Disabled students and other students in need of special support are entitled to receive – free of charge – special assistive devices and services which they need to allow them to take part in their classes. These assistive devices include computers, hoists or special desks (Basic Education Act, 628/1998).

Responsible authorities: municipal education service.

Support for the placement of people with disabilities in jobs

To support the placement of disabled people in jobs and their chances of keeping those jobs, employers can be granted funding for special arrangements in the workplace (Employment Services Act, 1005/1993).

Responsible authorities: labour authorities.

Assistive devices for disabled war veterans

The State Treasury is obliged, as part of its medical care, to arrange prostheses, equipment and assistive devices and to pay for servicing and replacement of these, as well as training on their use.

The State Treasury has to provide disabled soldiers with compensation amounting to at least 20 per cent for impaired ability to work, for costs relating to home adaptations, and for acquiring devices for the home (Act on injuries sustained in military service, 404/1948).

Responsible authorities: State Treasury.

Assistive devices after road traffic accidents, accidents at work or occupational diseases

Insurance companies reimburse costs as agreed for assistive devices required due to such accidents sustained at work as are referred to in the Accident Insurance Act (608/48), or such occupational diseases as are referred to in the Occupational Diseases Act (1343/1988), or such injuries sustained in road traffic accidents as are referred to in the Road Traffic Insurance Act (279/1959).

Responsible authorities: insurance companies.

Administrative rules and case management methods

The various acts are the only guidelines available, but they have proven to be open to various interpretations. Rehabilitation staff have expressed a need for national guidelines. STAKES has worked together with various parties to compile a quality recommendation for an assistive technology service. The Ministry of Social Affairs and Health and the Association of Finnish Local Authorities have published this quality recommendation in 2003.

Procedure for filing an appeal

There are clear rules on how to appeal against decisions made on the assistive technology service for which the welfare services, KELA and insurance companies are responsible.

The procedure is not the same for health and medical services. Here, the assistive technology service constitutes a part of the care ordered by the doctor. It is not possible to appeal against decisions on care made by a doctor. If anyone is dissatisfied with the assistive device solutions (care) they receive, they should send a memo to the senior consultant. If they are then dissatisfied with the decision of the senior consultant, they can send a demand for rectification to the health care board.

The case can be brought before the administrative court as an administrative dispute case. Complaints relating to decisions made by an administrative court may be lodged with the supreme administrative court.

Organisation and distribution of responsibilities

Health and medical services

At the end of 2002, there were 210 municipalities with their own health centres and 70 intermunicipal federations with health centres (consisting of 236 municipalities). These are responsible for primary health care and what are known as basic assistive devices, such as manual wheelchairs and assistive devices to help with walking and hygiene. The biggest health centres have assistive technology units, and the smaller ones have assistive technology teams run by the physiotherapy department.

There are 21 central hospitals with assistive technology units which are responsible for expensive, technically demanding assistive devices such as electric wheelchairs, hoists and environmental control systems. In addition, eye clinics, hearing clinics and lung clinics are all responsible for meeting the needs of their own patients with regard to assistive devices. The assistive technology units are also responsible for training and the planning of the assistive technology service for the district.

The allocation of various assistive devices to primary and special care varies from region to region. Doctors make decisions on the care and assistive devices required for medical rehabilitation.

Social services

Every municipality has its own social office which is responsible for providing services to disabled people in the municipality. Severely disabled people are entitled to home adaptations, as well as equipment and devices in their homes if their disabilities are such that they cannot manage without them. Social services pays for the cost of these upon application, and often consults the health care services before making decisions.

The Social Insurance Institution of Finland (KELA)

The Social Insurance Institution of Finland (KELA) has a total of more than 400 customer service points all over Finland. There are 258 full-service offices and around 130 branch offices. Rehabilitation can be applied for by applicants themselves, by the health care services, by the labour administration, by an educational establishment or by social services. Furthermore, the application may come via a doctor’s report submitted to the KELA in connection with an application for another benefit.

Applications must be accompanied by a doctor’s certificate stating the nature of the impairment and the problems this causes.

School system

Schools are responsible for providing special assistive devices for use by their disabled students in schools and classrooms. Rehabilitation staff who provide detailed recommendations regarding the devices required are often the people who apply for these measures.

Labour services

Employers apply for support from their local employment offices. Applications may also come from rehabilitation staff working with clients who are returning to the labour market after illness or disability.

State Treasury

The unit for military injuries and matters relating to veterans deals with the granting and payment of damages in accordance with the Act on injuries sustained in military service to people who have been disabled or fallen ill fighting our wars, as well as to their spouses, widows and other relatives. As a result of the same law, damages are also paid for injuries and illness among national servicemen, certain other people who have worked for the Armed Forces and people who have served in the UN’s peacekeeping forces. Compensation in accordance with the Act on injuries sustained in military service is payable for medical costs, costs for home adaptations and rehabilitation, among other things. Assistive devices are provided upon application, and the people themselves, rehabilitation staff or care staff can apply for them.

Financing

In the early 1990s, the overall cost of health and medical services fell by more than 10 per cent in real terms. Fees began to rise in 1995. In 1996, the overall costs for health and medical services accounted for 7.7 per cent of the national product. This is slightly lower than average for OECD and EU countries. The cost of health and medical services per inhabitant are also below the average for OECD countries (Ministry of Social Affairs and Health, 1999).

As far as the financing of health and medical services is concerned, the proportion of costs financed publicly has fallen, while households have taken on more significance as financial backers of all health and medical services. In 1996, almost a quarter of costs were born by households even then – one of the highest figures in the OECD countries. State finance has been reduced, while at the same time the proportion of charges paid by the municipalities has increased slightly. The importance of employers’ benevolent funds and private insurance to the financing of health and medical services costs has remained marginal (Ministry of Social Affairs and Health, 1999).

The State and municipalities

The State helps finance the municipalities’ extensive statutory tasks. The State shares system equalises the differences between various municipalities and ensures equivalent services for everyone. The State shares make up just under 15 per cent of the municipalities' income (24.2 per cent of welfare services and health care costs for 2001 for which State shares are justified). Municipal expenditure is financed by means of taxes, State shares, charges and income from sales. Finnish municipalities have the right to levy taxes. The municipal tax, property tax and share of corporation tax make up almost half of the municipalities' income. On average, citizens pay 17.5 per cent of their income in municipal tax. Just under a tenth of expenditure on welfare services and health care is covered by charges.

The municipalities arrange primary health care and special care for their citizens. In this way, first aid, rehabilitation and medical examinations and treatment are made available to everyone.

Primary care services are provided by health centres. Every municipality belongs to an intermunicipal federation for hospital districts that run hospitals in order to ensure that special medical care can be given.

The Social Insurance Institution of Finland (KELA)

Health insurance, which is administered by the Social Insurance Institution of Finland, supplements public health and medical services by reimbursing costs arising from the use of private health services and the cost of drugs for out-patient use. Health insurance is financed by means of the payments made by employers and the people insured. The State is responsible for ensuring that there is enough money in the health insurance fund.

Finland Slot Machine Association

The Finland Slot Machine Association (RAY) is an association governed by public law, with the purpose of acquiring funding for the promotion of activities in the public interest in Finland by providing games for the public. The profits of the Finland Slot Machine Association are divided in full among non-profit associations and for purposes in the public interest in Finland.

The biggest associations of people with disabilities arrange an assistive technology service with the support of the Finland Slot Machine Association. These organisations of people with disabilities provide advice and guidance to their members. They arrange courses and seminars on assistive technology. The Finnish Federation of the Visually Impaired and the Finnish Association on Mental Retardation (Communication and Technology Centre Tikoteekki) have their own assistive technology centres, and they sell their services (for assessing the need for assistive technology, for example) and hire out or sell products to municipalities’ health and welfare services, insurance companies and the KELA, among others.

The State Treasury, which is responsible for the rehabilitation of disabled war veterans, also receives money from the Finland Slot Machine Association to fund its work.

User influence

The central position of users in assistive technology matters is recognised. The Ministry of Social Affairs and Health emphasises the central position of clients in all its business plans. It could be said that user influence works in theory, but that health care staff are the ones who make the decisions in practice, particularly in the field of assistive technology.

The State and municipal disability councils (can be found in most municipalities) and the associations of people with disabilities have an important part to play when it comes to promoting user influence in Finland.

Central support functions

There is no comparative product information or national database of assistive technology. SAI-LAB r.f. (an association for suppliers in the laboratory and health care industry) maintains a database for the procurement units at hospitals and health stations, as well as a telecommunications systems between the organisations. This database includes information on products needed in hospitals or in the field of health care, along with information on suppliers. The SAI-LAB system is intended only for hospitals and health stations.

STAKES maintains a database, Apudata, of services and organisations in the field of assistive technology (www.stakes.fi/apudata).

No systematic national testing of assistive devices is carried out, apart from the testing carried out as agreed between the Nordic countries and EU regulation. The National Agency for Medicines is obliged to monitor companies that manufacture or sell assistive devices. Manufacturers and agents are obliged to report potential risks.

Some medical care districts purchase products jointly, but most assistive technology centres issue invitations to tender and price agreements themselves.

4 Provision of assistive technology in Iceland

Policy and principles for the provision system

Iceland’s policy on disabled and elderly people is based on the principle of non-discrimination, the compensation principle and the sector responsibility principle. Its legislation ensures that citizens receive the service they need, financed by the public sector, mainly the State, through taxes.

According to Icelandic law, there are three ministries responsible for the provision of assistive technology in Iceland: the Ministry for Health and Social Security, the Ministry of Social Affairs and the Ministry of Education, Science and Culture. The Ministry for Health and Social Security has the biggest part to play, and institutions subordinate to this ministry have been delegated responsibility for the provision of assistive technology. These institutions are the State Social Security Institute, which has the most essential responsibility in accordance with the Social Security Act, the Icelandic Low Vision and Rehabilitation Clinic in accordance with the Low Vision and Rehabilitation Clinic Act, the National Hearing and Speech Institute of Iceland, hospitals and institutions in accordance with the Health Services Act. Eight area offices under the auspices of the Ministry of Social Affairs are responsible for disabled people under 67 in accordance with the Act on people with disabilities. The municipalities are responsible for primary and lower secondary schools in accordance with the Primary and Lower Secondary Schools Act.

The State Social Security Institute is responsible for assistive technology in accordance with the Social Security Act and rules relating to assistive technology. Assistive devices must help to:

• improve people's abilities
• enhance the opportunities for self-help
• facilitate the care of people with disabilities.

Contributions of the State Social Security Institute towards assistive devices can be in the form of payment of a percentage of the cost of assistive devices (e.g. 50 per cent, 70 per cent or 100 per cent), specific amounts of money or a combination of both (e.g. 90 per cent, but never more than ISK 26 000). In general, the State Social Security Institute pays 100 per cent for the purchase of assistive devices which can be reused.

Administrative rules and complaints

Legislation is in place which deals with public casework, legislation on information and legislation on non-discrimination. There are consultative rules relating to time frames for casework, case notes, documentation and citizens’ rights to information on the casework, among other things.

It is possible to file appeals relating to all cases handled by the State Social Security Institute, including the allocation of assistive devices. The Social Security Ruling Committee deals with these cases.

Organisation and distribution of responsibilities

A lot of bodies from a variety of sectors play a part in work on the provision of assistive technology. It is important to involve all sectors concerned. Different bodies are involved depending on the case in question; but in addition to users themselves, the rehabilitation sector, the health sector, schools or workplaces, institutions responsible for assistive technology and – fpotentially – other bodies may all be involved.

The State Social Security Institute’s assistive technology centre holds overall responsibility for assistive technology for people living at home. The assistive technology centre ensures that assistive devices are provided for day-to-day activities in the home, assistive devices for driving, assistive devices for communication, orthopaedic assistive devices (such as orthoses, prostheses and orthopaedic shoes), single-use items (such as nappies, ostomy appliances, urine catheters and urine bags) and medical and treatment-related assistive devices (such as assistive devices for respiratory treatment, circulation treatment and injection equipment). The assistive technology centre is responsible for information, advice, casework, servicing (including maintenance), reuse, ranges, purchasing contracts, training, etc. In addition, contracts are drawn up with clinics for lung and oxygen services, for example; that is to say, relating to special services.

Purchasing contracts are in place in the following fields of assistive technology: assistive devices for walking, manual wheelchairs, beds and accessories, hoists, nappy and toilet assistive devices, orthoses, prosthetic arms and legs, nappies, urine catheters and urine bags, alarm units, oxygen equipment and servicing, and CPAP/BIPAP equipment and servicing.

Rules on entitlements to assistive devices can be found at the State Social Security Institute website at www.tr.is under “hjálpartækjamiðstöð” (the assistive technology centre). The rules are divided up into general rules on entitlements and definitions, and into detailed rules split up according to the classification system for assistive devices, in which more information is given on conditions and the contributions of the State Social Security Institute.

The National Hearing and Speech Institute of Iceland is responsible for hearing rehabilitation and assistive devices for hearing impaired people and people with speech impairments. The National Hearing and Speech Institute is responsible for information, advice, casework, servicing, reuse and purchasing.

The Icelandic Low Vision and Rehabilitation Clinic is responsible for rehabilitation and assistive devices for blind and visually impaired people. The Low Vision and Rehabilitation Clinic is responsible for information, advice, casework, servicing, reuse and purchasing.

Area offices (eight offices all over the country) are responsible for assistive devices for people aged 16 and over who are studying and for people aged 18 and over who are working.

Hospitals and institutions (including care homes for the elderly) are responsible for assistive devices for their patients/residents.

Primary and lower secondary schools are responsible for assistive devices for their students.

There are other knowledge centres which provide advice in specific fields with regard to assistive devices, including the Computer Centre for People with Disabilities, which is run by user associations and organisations of people with disabilities.

Financing

Assistive devices are financed mainly by the State, but municipalities deal with assistive devices used in primary and lower secondary schools. Assistive devices are mostly provided free of charge to users, but users have to pay something towards certain assistive devices. The user has to pay 10 per cent towards the cost of orthopaedic shoes and 30 per cent of the cost of orthoses when they will be used for less than twelve months, for example.

The authority approving the provision of assistive devices buys and owns them. Reusable assistive devices have to be returned once they have been used.

Central support functions

The State Social Security Institute’s assistive technology centre, the National Hearing and Speech Institute of Iceland and the Icelandic Low Vision and Rehabilitation Clinic are national knowledge centres in the field of assistive technology and its availability to people with disabilities or impaired hearing, sight or speech. The aim of the provision of assistive technology is to increase the extent to which disabled and elderly people can play a part in society by using good assistive devices and making them more able to play an active part in society. These centres encourage development and stand responsible for the provision of information and training.

The State Social Security Institute has recently set up a database for the provision of assistive technology, and this is constantly undergoing development. It meets the demands made of information, statistics, searches, etc. and will meet demands for electronic connections. The use of the ISO classification system for assistive devices in the provision system and database ensures that there are opportunities for comparing the provision of assistive technology across national borders, among other things.

The State Social Security Institute’s assistive technology centre has been working together with the State Trading Centre (Ríkiskaup) since 1994 on the range of assistive devices available. Its aim is to enter into contracts with the suppliers of assistive devices so as to acquire good, safe assistive devices at favourable prices. The assistive technology centre has set up a reference group tasked with recommending relevant assistive devices. This reference group is made up of staff from the assistive technology centre, the rehabilitation sector and users.

The State Social Security Institute’s assistive technology centre holds information meetings with suppliers, user groups, rehabilitation centres/departments and health centres with a view to creating a platform for the dissemination and exchange of information.

Nordic cooperation in various fields with regard to the provision of assistive technology is important for the development of assistive technology in Iceland.

5 Provision of assistive technology in Norway

Policy and principles for the provision system

The Government’s action plan for disabled persons defines disability as follows: “Disability is a discrepancy between the abilities of an individual and the demands of society in respects essential for the individual to maintain independence and a social existence.” (The Government’s action plan for people with disabilities 1994-1997, Department for Health and Social Affairs and the White Paper no. 8 1998-99: About the action plan for people with disabilities 1998-2001.)

People with disabilities encounter:

practical problems, because they are unable to meet the expectations from their surroundings and as a result, many find themselves being on the periphery of society with regard to important issues.

Being disabled can be described as a “gap” between what individuals can do and what society demands from individuals in terms of function. Therefore, disabilities are situation-specific. In other words, the practical problems are dependent on the gap between what society demands and what people can do. Assistive devices, accessible environments, technical measures and personal assistance can all help lessen society's demands in terms of function, thereby allowing people to live more independent lives. The more accessible the surroundings are, the less people need special solutions.

The effects of disabilities can also be reduced both by making people more capable and doing something about society's demands. People can be made more capable by giving them training, education, care and support. Society's demands can be altered by adapting the surrounding environment and making it accessible.

Assistive devices and personal assistance can be employed to lessen the “gap” between demands and abilities.

Rules on support for assistive technology

Assistive devices for use in the home, etc.

The term “assistive devices” includes “any assistive devices and any ergonomic solution that can reduce the disability”. That means:

• Assistive devices used close to the body
• Assistive devices for use in training
• Assistive devices.

Assistive devices help to compensate for disabilities and include many groups of assistive devices such as tools to assist communication and movement, low vision aids, hearing aids, cognitive aids, devices to stimulate and encourage activity, ICT-related devices and specially adapted cars.

Treatment devices also used to be the responsibility of the national health insurance scheme, but this responsibility was essentially transferred to health organisations (hospitals) from 1 January 2003.

Assistive devices must be part of a rehabilitation plan and help to:

• Enhance the capabilities of people with disabilities
• Enhance the self-sufficiency of people with disabilities
• Facilitate the care of people with disabilities

People suffering from a long-term disability (more than 2-3 years) and significantly impaired abilities due to illness, injury or physical defects can receive support for assistive devices from the national health insurance scheme. People who temporarily need assistive devices have to apply for support from their municipalities.

In addition, the assistive devices must be necessary and appropriate for enhancing disabled people’s abilities to solve practical problems in their day-to-day lives, or for ensuring their care at home. The national health insurance scheme usually provides support for the most reasonable of the types of assistive device that meet the needs of the user in question.

No support is provided for assistive devices that are normally used by non-disabled people examples are washing machines, televisions and general kitchen equipment. However, support is given for additional equipment required to adapt such equipment.

A number of departments are responsible for providing assistive devices for people with disabilities. Department for Health and Social Affairs (SOS) and the National Insurance Administration have the greatest part to play in respect of assistive devices covered by the National Insurance Act. Paragraph 10 of the National Insurance Act regulates aid for assistive devices.

Other departments also have important parts to play as regards assistive devices. The Ministry of Transport and Communications and the Ministry of Education and Research are two examples. One is responsible for transport and telecommunications services, while the other is responsible for education, training and research. Both of them are responsible for preparation and information for the public areas that they control.

Assistive devices for use at work and in education

The national health insurance scheme can provide support for assistive devices, converting machinery and adapting the physical environment in the workplace. Support is given if it is appropriate and necessary to allow the disabled person in question to find a job as part of vocational rehabilitation or to keep a suitable job. By “a suitable job”, we mean a job which the user is capable of mastering, given his or her physical and intellectual capabilities.

In accordance with the Working Environment Act, § 13, employers are responsible for ensuring that the workplace is adapted for disabled employees. Nevertheless, support can be provided by the national health insurance scheme to allow disabled employees to keep suitable jobs.

If support is provided to place disabled people in a position to acquire suitable jobs, this is often part of vocational rehabilitation. In this instance, a rehabilitation action plan must exist which has been prepared by the rehabilitation applicant and the local labour office. Support can be given for assistive devices that disabled people need for education at college or university level, even if the education is not part of vocational rehabilitation. Support can also be given for assistive devices for self-employment if this is necessary for the disabled person in question to be able to continue to trade.

Assistive devices for exercise, stimulation and encouragement of activity

The national health insurance scheme can provide assistive devices for exercise, stimulation and to encouragement of activity among children and young people. From January 2003 people with disabilities aged up to 26 receive this kind of support. Special and additional equipment is also provided for games and sport, but this equipment has to be specially designed for disabled people or necessary for them to carry out the activity in question. Examples of this equipment include switches for games, skis for the disabled and the like. No assistive devices are provided for competitive sports or ordinary games, or sports equipment.

Assistive devices for other purposes

The national health insurance scheme provides assistive devices and other measures for other purposes. However, there are a number of conditions attached to several of the areas, such as limits on the amount of aid that can be given or the number of hours over a year. Special rules apply to the following areas:

• Hearing aids and interpreters for people with hearing impairments:
• Interpreters and escorts for deaf-blind people
• Guide dogs and assistance with reading and secretarial services for visually impaired people
• Basic pattern for seams of clothing
• Computer equipment
• Assistive devices at school
• Motor vehicles and other modes of transport
• Standard computer equipment

Assistive devices for use in primary and lower secondary schools and upper secondary schools (assistive devices at school)

Users in compulsory education can receive aid from the national health insurance scheme for assistive devices that alleviate practical difficulties in the school environment, while schools provide aid for assistive devices linked with individual subjects. Aid for computer equipment is given to users suffering from disabilities that such equipment could directly help to alleviate, as well as providing such equipment in cases in which it is necessary so as to allow users to benefit from educational programmes provided by their schools.

Assistive devices for communication

Communication assistive devices are provided in accordance with the regulation on assistive devices for use in day-to-day life, and the assessments for this will be the same as for the assessment of other assistive devices for this purpose. In other words, the user must be unable to communicate in other ways, and the assistive device must be the most reasonable option to alleviate the difficulties with communication. It should be mentioned that computer equipment – including digital photographic equipment – is provided in accordance with special guidelines set by the National Insurance Administration, and as far as assessing digital photographic equipment for use in communication is concerned, the guidelines state that the user must have severe communication problems before aid can be given.

Subsidies for standard computer equipment

As far as support for standard computer equipment is concerned, the rules were amended as of 1 January 2003, from a loan arrangement to a subsidy arrangement. This means that a fixed subsidy is granted to buy a standard computer from the Assistive Technology centre. Equipment provided subject to the subsidy system becomes the personal property of the individual concerned. The user may choose where to buy the equipment as long as the supplier is able to offer 4-year contracts for servicing, support and insurance. Applications for new equipment can only be submitted every four years.

The target group is users who do not have complex problems or progressive illnesses and who need standard computer equipment for use in their day-to-day lives – including at school – for more than a year. The users entitled to computer equipment who do not fall under the auspices of the subsidy system receive aid for their computer equipment in the form of a loan from the national health insurance scheme.

Administrative rules

In Norway, a project has been implemented with regard to individual plans for use as a foundation for assistive devices, and this has now been continued as a regular arrangement. The use of individual plans has laid the foundation for significant simplification of the provision of assistive devices to users with such plans. Throughout the entire plan period, users are able to receive loans of assistive devices covered by the plan without having to apply for them in the usual way. All they have to do is tell a contact within the municipality that they need a new assistive device, and the national health insurance scheme will lend it to them.

Users who need long-term, complex services from the public sector are entitled to such plans, and a corresponding obligation rests with the health service to prepare such plans for these users. It must be emphasised that responsibility for preparing such plans often rests with the municipal health service, and even if the national health insurance scheme is unable to initiate or prepare individual plans, the national health insurance scheme could use such plans as a foundation for the lending of assistive devices.

Appeals and complaints, etc.

If users feel that their requests have not been granted fully, they can appeal against the decision to an appeals authority within six weeks. If the appeal to this authority is not successful, a further appeal on the decision of the appeals authority can be submitted to the National Insurance Court of Appeal. The National Insurance Court of Appeal is an administrative body and not a regular court, and a decision made by this body can be brought before the regular court.

Organisation and distribution of responsibilities

A number of Government departments and sectors have to work together to bring about a consistent assistive technology solution. Users have a lot of different people to consult. These bodies have to work together with users and aim for shared objectives if the solutions they provide are to turn out well.

The provision of assistive technology requires skills from various sectors and at various levels. It is important to involve all the sectors concerned. Both simple and more complex problems can be resolved at front-line level if the municipality has its own experience of similar problems. Rare and more complex problems often require specialist skills from a higher level of competence. People are encouraged to ask for advice and guidance from the Assistive Technology centres if their own skills are insufficient.

Municipalities are responsible for health and rehabilitation for all their citizens. The provision of assistive technology is part of that responsibility. The Assistive Technology centres are a second-line service and a resources and competence centre as regards the provision of assistive technology for the entire local council. There are 19 Assistive Technology centres in Norway, one in each county. These centres are all a part of a national system run by the National Insurance Administration. A nationwide car centre, SUITE (Sunnaas Information Technology unit), NONITE (Northern Norway IT unit) and a nationwide service for deaf-blind people are competence centres at third-line level, again part of the National Insurance Administration. These are all specialists in individual fields with regard to the provision of assistive technology, and they serve users, front-line and second-line services all over Norway.

Provision of assistive technology

If assistive devices are to be provided, there has to be a practical problem for a user as a consequence of disability, be it physical or intellectual. This requires an investigation of the overall situation for the user and a target for the provision of assistive devices. This should be included in a treatment plan, care plan, training plan, rehabilitation plan or vocational rehabilitation plan.

One or more assistive devices are selected once various possibilities have been tested and assessed. Specialists can consult their Assistive Technology centres in order to borrow assistive devices for testing.

An application (requirement form) is then drawn up and submitted to the Assistive Technology centre for assessment and a decision. It is important for the application to be sufficiently detailed and justified on the basis of relevant information. This helps to speed up the process.

If the Assistive Technology centre approves the application, the assistive device is sent to the user. The assistive device often has to be adapted and adjusted, and more major adaptations may sometimes be required. The Assistive Technology centres deal with this.

Reasonable guidance, training and practice on the use of the assistive device are just as important as the assistive device itself. The assistant who recommended the assistive device must also stand responsible for following up and working together with the user to assess whether the device does actually solve the user's problems, and whether further training or adaptation is required.

The user must receive both verbal and written information on who to contact, and where, if the device needs servicing or repairs.

The process must be evaluated in order to check that the user has received useful assistance and the right assistive device within an expected time frame.

Financing

Assistive devices are financed by State funding – the Storting (Norwegian parliament) grants money to the “Assistance budget”. The budgets are prepared for each of the 19 Assistive Technology centres on an annual basis. The National Insurance Administration is responsible for the budget.

The allocation of assistive devices is based on individual rights for the user. This means that if the users meet the criteria enabling them to receive assistive devices, the devices must be acquired even if the budget is exceeded.

For some assistive devices, such as hearing aids, there is a user’s co-payment.

Central support functions

The Division of Assistive Technology Supply Contracts comes under the control of the National Insurance Administration. This division is responsible for entering into contracts with suppliers of assistive devices in Norway. It is mainly when the major assistive device groups such as manual and electric wheelchairs are involved that the Division of Assistive Technology Supply Contracts enters into framework agreements with individual suppliers. Assistive devices subject to framework agreements make up a national standard. The intention behind framework agreements is to ensure that a national range of good quality devices is available at a reasonable price.

The Assistive Technology centres select their local ranges from the national range. The National Insurance Administration does not enter into framework agreements for the smaller assistive device groups such as ADL aids. The Assistive Technology centres enter into agreements directly with suppliers in this instance.

Reference groups have been set up for the various product areas. These reference groups consist of staff from the Division of Assistive Technology Supply Contracts, the Assistive Technology Division, specialists from the Assistive Technology centres and users themselves. The role of the reference groups is to recommend relevant products for which price negotiations would be desirable.

The National Insurance Administration keeps a national assistive technology database. This “Assistive technology database” was commissioned in September 2000. Norway is working together with Sweden and Denmark on technical development of the database. The database is still under construction. Suppliers will gradually be made responsible for entering relevant information on the various assistive devices in the database. Data will be entered according to a specific template.

All in all, five national standards have been developed for the field of assistive technology. These are: “National standard for front-line training”, “Emergency repairs to assistive devices”, “Ambulance service activities”, “Testing assistive devices” and “Range work at assistive technology centres”. The national standards describe the quality of service that can be expected from the Assistive Technology centres.

By publishing the national standards in booklet form, municipalities and other partners are able to find out about the work of the Assistive Technology centres and the demands made of these centres. Consequently, this will give them more realistic expectations of what these centres can and should do.

The national standards also help with developing a consistent national service. These standards must ensure that the procedures in a specific field or for a specific service are the same for all local councils.

The existing national standards are now going to be assessed. Although ongoing assessment of the existing standards is taking place, there is also a need to create standards for other fields with regard to the provision of assistive technology.

6 Provision of assistive technology in Sweden

Policy and principles for the provision system

The objective for policy on disabilities is to bring about a society which makes it possible for people with disabilities to be fully active members of society. The fact that all people are equal is a basic starting point as regards how society should be formulated, and people with disabilities are citizens with exactly the same rights and obligations as everyone else. This is expressed quite clearly in the national action plan for disability policy, “Från påatient till medborgare” [From patient to citizen] decided upon by the Riksdag (Swedish parliament).

Access to assistive technology which works well is crucial if the objectives of the policy on disabilities are to be attained.

Assistive devices are products which people with disabilities need in order to:

• prevent future losses of function or ability
• improve or maintain function or ability
• compensate for impaired or lost function and ability to cope with day-to-day life.

A State analysis of assistive technology is in progress at present, and this will be completed in 2004. The tasks of this analysis is to review assistive devices for use at work, at school plus general principles on fees for the user and principles on ICT devices etc.

Rules on support for assistive technology

Assistive devices in the home, for treatment, etc.

County councils and municipalities, according to the Health and Medical Services Act (§ 3 b and § 18 b), are obliged to provide people with disabilities with assistive devices. The Health and Medical Services Act is an obligation act for county councils and municipalities, but it does not entitle individuals to assistive devices. There is no right of appeal to a court against decisions on assistive devices.

Within the scope of the Health and Medical Services Act, county councils and municipalities may themselves decide on rules for assistive devices, such as which products are to be regarded as assistive devices and be available for prescription to people with disabilities. They also decide on any charges. Therefore, the chances of receiving a specific assistive device may vary, depending on where you live in Sweden.

Assistive devices according to the Health and Medical Services Act include assistive devices to aid with day-to-day life and for care and treatment.

Assistive devices aim to assist individuals to carry out the following tasks themselves or with the help of someone else:

• meet basic personal needs (getting dressed, eating, personal hygiene, etc.)
• move around
• communicate with society
• function both in home and around the local area
• find their way around
• carry out day-to-day tasks in the home
• go to school or college
• take part in normal leisure and recreation activities.

Assistive devices in the field of teaching and training

Assistive devices for use in schools and colleges may include:

• personal assistive devices
• educational aids
• basic equipment.

Personal assistive devices in schools and colleges – assistive devices at school – are assistive devices which individual students need to compensate for their disabilities so as to be able to take part in classes. The public health authority – the county council or municipality – is responsible for this, using the Health and Medical Services Act as its foundation. Health and medical services staff, such as occupational therapists, speech therapists and physiotherapists, are responsible for assessing the need for appropriate assistive devices and prescribing them.

The public health authority’s responsibility for offering assistive devices at school applies to the following types of school:

• primary and lower secondary schools, including special schools
• upper secondary schools
• colleges/universities
• State and municipal adult education.

All schools are responsible for buying assistive devices at school, although these are not a responsibility in accordance with the Health and Medical Services Act.

The public health authority is responsible for providing educational aids and basic equipment, as well for adapting the premises. Students with disabilities sometimes need special educational aids. In primary and lower secondary schools, including special schools, upper secondary schools and independent schools under State supervision, acquiring and funding these educational aids is the responsibility of the school.

The boundaries between the responsibilities of schools and the responsibilities of the health and medical services may vary depending on what has been agreed with the public health authority. The State analysis of assistive technology which is in progress at present will also review assistive devices in schools, including the problem of where the boundaries lie.

Assistive devices for use at work

Assistive devices which allow people with disabilities to work are known as assistive devices at work and are the responsibility of the county labour boards and social insurance offices. The assistive devices required by employees to prevent injuries from being sustained at work are the responsibility of employers and are known as assistive devices for staff.

Assistive devices at work are assistive devices which people with disabilities need at work but are not normally required for work. Workplaces may also need to be adapted to accommodate disabled people. Responsibility for assistive devices at work and/or converting the workplace is shared between the social insurance office and the Swedish Employment Agency. The social insurance office is responsible for assistive devices at work required to allow staff to continue their employment, while the Swedish Employment Agency is responsible for ensuring that people with disabilities can actually work in the first place. Any employee with a disability which makes it difficult to do their work, has been affected by long-term illness, is undergoing rehabilitation or needs help to get back to work can receive a grant through the social insurance office for personal assistive devices at work. Employees/self-employed people and employers can all receive these grants.

The Swedish Employment Agency is responsible for assistive devices at work required to help staff take on new positions when switching jobs or after a period of unemployment. The Swedish Employment Agency is also responsible for assistive devices that are needed by young people with disabilities during their practical work experience and for costs for talking books and Braille books required by visually impaired people to allow them to take part in labour market training.

The social insurance office and the Swedish Employment Agency often engage the services of rehabilitation and assistive technology specialists in these cases.

There are other rules and support systems for the adaptation of homes and cars.

Organisation and distribution of responsibilities

Assistive technology constitutes part of other care and habilitation/rehabilitation efforts provided by the public health authority, county councils and municipalities. There are 21 county councils/region and 290 municipalities in Sweden.

Assistive devices to be used in the home, the local environment and at school in order to facilitate day-to-day life and for care and treatment are the responsibility of the public health authority, i.e. county councils and municipalities. Health and medical services staff at various units within county councils and municipalities prescribe assistive devices.

County council level

At district health centres or their equivalent in primary health care, most assistive devices are prescribed to people with physical disabilities. At these centres, there are doctors, nurses, and often also occupational therapists and physiotherapists who can assess the need for assistive devices and prescribe them. People can also be referred to other units, such as hearing centres or low vision centres, from here.

Staff at assistive technology centres usually act as consultants for the people within county councils and municipalities who prescribe assistive devices mainly to people with physical disabilities, speech impediments and language impairment disorders, and cognitive and medical disabilities. Consultation takes place with regard to complex or unusual assistive devices, or when adapting assistive devices. Assistive technology centres provide information and also train people who prescribe – and other people as well – on assistive devices. These centres have another important function, too; they provide assistive devices prescribed.

The hearing centres or their equivalent are responsible for hearing rehabilitation. This involves carrying out hearing tests, testing, adapting and prescribing hearing aids and other hearing devices and training people in their use. The hearing centres also provide information to the relatives of the hearing impaired.

The Interpreter Centres and Speech Service centres are responsible for interpreting for the deaf and hearing impaired, as well as for people with speech impairments. The interpreter centres often prescribe text telephones.

The low vision centres are responsible for the rehabilitation of visually impaired people. This involves investigating, assessing the need for and prescribing assistive devices, as well as teaching people how to get started, read and move about.

The orthopaedic workshops often work on behalf of county councils. These are responsible for assessing the need for and producing orthoses, prostheses and orthopaedic shoes after referral by a doctor.

Habilitation and rehabilitation units are responsible for treating children, young people and adults with congenital disabilities, primarily physical disabilities and multiple disabilities. Assistive devices form part of their treatment and are prescribed by occupational therapists, physiotherapists and speech therapists working in habilitation.

Certain medical clinics operating in the field of in-patient care, such as lung clinics and diabetes units, are also responsible for assistive devices in their respective fields.

At speech therapy clinics, assistive devices are prescribed for people with speech impairments and language disorders, and they are given training in alternative methods of communication. Some county councils offer what are known as communication centres, which deal with more complex communication analyses and also train staff.

Specialist skills in assistive devices based on advanced computer technology are available at assistive technology centres or as special computer resource centres under some county councils.

At Children’s Computer Centres (Datateks), often provided as part of habilitation services, children with disabilities who are unable to read or write yet are able to try out different kinds of computer software. They can also borrow computer software and control devices for use on their own computers at home.

Municipality level

The municipalities are responsible for health and medical services for the elderly and people with disabilities in special accommodation, and in their own accommodation as well in some municipalities. This also involves responsibility for rehabilitation and assistive devices, primarily for people with physical disabilities. Many municipalities have rehabilitation units employing occupational therapists and physiotherapists which are responsible for this work, which also includes assessing the need for, prescribing and training on assistive devices. There is often close cooperation with county councils’ assistive technology centres.

Staff at special accommodation, home help staff and relatives also help to ensure that assistive devices prescribed are being used correctly.

A number of municipalities have home instructors whose job it is to help visually impaired and hearing impaired people to enjoy more active lives by helping to train them in how to use their assistive devices, for example.
Nurses with Medical Responsibility are the people responsible for quality and safety in the field of municipal health and medical services, which also include rehabilitation and assistive devices. Some municipalities also have people with medical responsibility for rehabilitation.

The municipalities are responsible for home adaptation grants which can be obtained for measures deemed necessary to allow people to remain in their own homes. Certificates from occupational therapists, doctors or equivalent must be obtained to apply for these grants.

The prescription process

Assistive devices for people with disabilities are prescribed by health and medical services staff in accordance with the Health and Medical Services Act. The process of prescribing assistive devices is a part of habilitation or rehabilitation for which special habilitation or rehabilitation plans must exist. These plans should include planned measures such as the prescribing of assistive devices, who is responsible for the measures and what they aim to achieve. Patients should take part in the planning of measures as far as is possible.

Around 70 per cent of assistive devices prescribed go to people aged over 65. If visual, hearing or orthopaedic assistive devices are required, patients are often referred to low vision or hearing centres or to orthopaedic workshops. A vast number of visual, hearing and orthopaedic assistive devices are prescribed at these units, and county councils essentially hold responsibility for these assistive devices.

In the case of other assistive devices (to help with physical disabilities, cognitive disabilities, etc.) provided via assistive technology centres, this responsibility is shared between county councils and municipalities. The people prescribing the assistive devices – usually occupational therapists, physiotherapists, speech therapists and district nurses – may be employed by either the county council or the municipality, and assistive devices are largely prescribed by their own staff within the primary health care service of the municipality or county council. Assistive technology specialists at assistive technology centres are consulted when anyone prescribing an assistive device feels that they are not skilled enough to prescribe such a device.

Some assistive devices, such as ventilators, CPAP equipment for snoring problems and inhalers, are also prescribed using the Health and Medical Services Act as a foundation. However, slightly different procedures may apply, as clinics at hospitals are often responsible for prescribing and following up these assistive devices.

People prescribing assistive devices are staff who select appropriate, specific products for named patients on the basis of requirement assessments. The people prescribing assistive devices decide on which assistive devices to prescribe, given the applicable rules within the public health authority by which they are employed. In some cases – often in the case of expensive assistive devices – a formal decision is also made to approve the prescription before the assistive device in question can be purchased.

The prescription process is the same regardless of the field of assistive technology involved, the professional category responsible for prescribing or the public health authority concerned. The prescription process consists of a number of phases in which one and the same member of health and medical services staff can stand responsible for the entire process, or just for parts of it. It is essential for responsibilities to be clarified for the various phases, such as in the rehabilitation plan, and for the functioning information transfer to be implemented throughout the entire care chain.

The prescription process consists of the following phases:

• assessing the need for assistance
• assessing, adapting and selecting an appropriate, specific product
• if so required – initiating and preparing instructions for special adaptation
• instructing, training and providing information
• following up and assessing the function and benefit of assistive devices.

For more information on the respective phases, please see the Swedish Handicap Institute’s document entitled “Förskrivningsprocessen för hjälpmedel till personer med funktionshinder” [The prescription process for assistive devices for people with disabilities], order no.: 00336. However, the text is only available in Swedish.

Appeals

Formally, there is no right of appeal to a court against the prescription of assistive devices. The Health and Medical Services Act is an obligation act for the public health authority, but it does not entitle patients to assistive devices. Anyone who is not happy with a decision can appeal to the operations director and/or patient boards at county councils and municipalities.

User influence

Users have a large and vital part to play in assistive technology activities. Their participation and influence are brought to bear in a variety of ways. As individuals, they take part in and influence their own rehabilitation and the prescription of assistive devices. Here, great emphasis is placed on the fact that users must be given genuine opportunities to properly take part in this process.

Users are also able to exert influence through the many well developed organisations of people with disabilities. There are various methods of cooperation in respect of assistive technology activities. The county councils have joint consultation bodies, Disability Ombudsmen, where organisations regularly consult with politicians and officials with regard to assistive technology issues, among other things. Units working in the field of assistive technology activities, such as assistive technology centres, low vision centres and hearing centres, have special range groups or user councils where relevant questions can be addressed. These organisations also run – either on their own, or in coordination with assistive technology activities – various projects relating to rehabilitation and assistive technology.

Financing

Assistive devices are paid for by county councils and municipalities and are essentially free of charge to users. The distribution of responsibility is described in the section entitled Organisation and distribution of responsibilities. Separate fees are payable by users for certain assistive devices; orthopaedic shoes, wigs and hearing aids, for example. It is also usual for users to pay for consumer goods such as tyres for wheelchairs, batteries, etc..

Assistive devices for use at work are financed by the social insurance office, the Swedish Employment Agency or employers and are free of charge to users.

Central support functions

The Swedish Handicap Institute (HI) is a national resource centre on assistive technology and accessibility for people with disabilities. The Swedish Handicap Institute works to promote full participation and equality for people with disabilities by ensuring access to high-quality assistive technology, effective provision of assistive devices and an accessible environment. The Swedish Handicap Institute encourages research and development, tests and procures assistive devices, assists with the development of knowledge and methods, and provides information and training. The Swedish Handicap Institute’s principals are the State, the Federation of Swedish County Councils and the Swedish Association of Local Authorities.

The Swedish Handicap Institute

• works to develop and improve assistive devices, assistive technology activities and accessibility in society for people with disabilities
• works with the development of knowledge and methods and carries out health economic studies
• works together with and assists municipalities and county councils, central bodies, organisations of people with disabilities, companies and other organisations by providing them with expertise in the field of assistive technology
• encourages research and the use of new technology and Design for All
• supports the development of new assistive technology by making contributions to the manufacturers of assistive devices, among other things
• works with testing and standardisation with a view to producing safe assistive devices
• provides information and disseminates knowledge and experience, and provides coordination and cooperation on both a national and an international basis in the field of assistive technology
• makes coordinated purchases for the public health authorities so as to allow it to offer high-quality, safe assistive devices that offer good value for money to people with disabilities, and helps ensure a cost-effective supply of assistive devices to the public health authorities.

The Swedish Handicap Institute issues information documents and books written for both users and staff. The HIDA product database, which can be accessed via the Internet, also provides information on assistive devices. The Swedish Handicap Institute also has the biggest specialised library in the Nordic region as far as assistive technology and disabilities are concerned.

The Swedish Handicap Institute (SHI) is a national resource centre on assistive technology and accessibility for persons with disabilities.

We work for full participation and equality for persons with disabilities by ensuring access to high-quality assistive technology, an effective provision of assistive devices and an accessible environment.

The activities of the Swedish Handicap Institute cover:

• testing and procurement of assistive devices
• research and development
• analyses of needs, knowledge and method development
• training and capacity building
• accessibility and design for all
• training and capacity building
• international cooperation
• information

The Swedish Handicap Institute is run by the Ministry of Health and Social Affairs, the Federation of Swedish County Councils and the Swedish Association of Local Authorities.