Some persons with disabilities die up to 20 years earlier than people without disabilities. That is the World Health Organization’s own figure, from its work on health equity for persons with disabilities. That gap does not only sit in poor countries or distant institutions. It sits inside our own clinics.
The usual response is to talk about access: ramps, lifts, accessible toilets. Those matter. But the argument here is that physical access is the easy part, and that focusing on it lets health systems avoid the harder truth. Much of the gap is produced by how clinicians think, how appointments are designed and how health data is collected. That is a problem inside the consulting room, not just at the front door.
The scale of what we are missing
WHO estimates that 1.3 billion people experience significant disability, about one in six people worldwide. Its 2022 Global report on health equity for persons with disabilities made the point that many of the health gaps they face are not caused by their underlying condition. They are caused by avoidable factors: unfair treatment, inaccessible services and the wider conditions in which people live.
WHO’s fact sheet puts some of it in numbers. Persons with disabilities have twice the risk of developing conditions such as depression, asthma, diabetes, stroke, obesity or poor oral health.
One in six of the population, with double the risk of several common chronic diseases. This is not a niche caseload. It is a large share of the people already in our waiting rooms.
Diagnostic overshadowing
One of the most important mechanisms is also one of the least discussed outside disability circles. It is called diagnostic overshadowing: the tendency to attribute new symptoms to a person’s existing disability rather than investigating them.
A person with an intellectual disability becomes agitated, and staff assume it is behavioural when the cause is pain from an untreated dental abscess. A wheelchair user reports fatigue and weight loss, and it is put down to their condition rather than worked up for cancer. The disability becomes the explanation for everything, and ordinary illness goes unrecognised.
No ramp fixes this. It is a habit of thought, and it has to be trained out of clinicians deliberately.
The fifteen-minute appointment problem
The second mechanism is structural. Much of primary care is organised around short, standardised appointments. That design works tolerably for a patient who can climb onto an examination table, hear clearly, read a leaflet and explain their symptoms quickly.
It works badly for someone who needs help to transfer, uses a communication device, needs a sign language interpreter or needs information in easy-read format. For these patients, a standard slot is not neutral. It systematically produces worse care, because there is not enough time to do the examination or understand the history properly.
Adjustments such as longer appointments, accessible equipment like height-adjustable tables, and alternative communication formats are sometimes framed as extras. They are the minimum needed for an equivalent consultation.
Why systems underinvest
There is an incentive problem underneath this, and it deserves naming.
Most health systems pay providers per visit, per procedure or per enrolled patient, with little adjustment for the extra time and support some patients need. A clinic that takes longer with patients who need it is, in financial terms, penalised. A clinic that rushes them, or quietly discourages them, is rewarded.
Data makes it worse. Many health information systems do not reliably record disability status, so disparities in screening, vaccination or chronic disease management stay invisible. What is not measured is not managed, and what is not managed is easy to deprioritise.
The economic case is stronger than people assume
Inclusion is often presented as a cost that must be justified on rights grounds alone. The rights case is sufficient on its own. But the economic case is also better than many assume.
WHO estimates there could be a return of almost US$10 for every US$1 spent on implementing disability-inclusive prevention and care for noncommunicable diseases. That reflects the costs avoided when conditions are caught earlier, managed properly and prevented from progressing to disability-compounding complications.
Finance ministries tend to take that kind of ratio seriously. Advocates should use it.
What inclusive services look like in practice
The practical agenda is concrete, and much of it is within reach of individual services.
- Record disability status and required adjustments in patient records, with consent, so staff know in advance what someone needs.
- Build flexible appointment lengths into scheduling and payment, rather than relying on individual goodwill.
- Train clinicians on diagnostic overshadowing, with the involvement of persons with disabilities themselves.
- Buy accessible equipment as part of routine procurement, not as a special project.
- Involve organisations of persons with disabilities in designing and evaluating services. The disability rights principle of “nothing about us without us” applies to health care as much as anywhere.
A cancer screening appointment, twice
Consider two versions of the same cervical screening appointment. The scenario is illustrative.
In the first, a woman who uses a wheelchair books a standard slot at her local practice. When she arrives, the examination table does not lower. There is no hoist. The nurse is kind but pressed for time, and there are other patients waiting. They agree to “try another time.” The next invitation comes months later. The same thing happens. Eventually she stops booking. In the practice’s records, she is simply overdue for screening, like many other women who did not attend. Nothing flags that the practice, not the patient, was the reason.
In the second version, the practice records at registration that she needs a height-adjustable table and a double appointment. The booking system allocates the right room automatically. The nurse knows in advance. The screening takes place on the first visit.
The difference between the two is not a grand policy. It is a data field, a piece of equipment and a scheduling rule. Multiply that difference across screening, vaccination, dental care, diabetes checks and blood pressure monitoring, and it helps explain how large gaps in outcomes can build up without anyone deciding to exclude anyone.
The strongest counterargument
The most serious objection to disability-inclusive reforms is about resources and priorities.
Health services are overstretched. Longer appointments for some patients mean fewer appointments for others. Accessible equipment costs money that could be spent elsewhere. Training on diagnostic overshadowing competes with dozens of other training requirements. Some argue that it is more efficient to concentrate expertise in specialist disability services than to adapt every general practice and hospital ward.
This holds in part. Resources are finite, and specialist services have an important role, particularly for complex conditions. Not every clinic can have every piece of equipment.
But the argument has limits. First, most health needs of persons with disabilities are ordinary health needs: infections, heart disease, cancer screening, dental care, pregnancy. Sending people to specialist services for routine care is neither efficient nor what most people want. Second, many adjustments are low-cost once built into routine systems: recording needs, adjusting appointment length, providing information in accessible formats. The expensive part is often the failure to plan. Third, the costs of exclusion do not disappear. They reappear as late diagnoses, avoidable admissions and preventable complications, which is part of what WHO’s estimated return on investment captures.
There is also a legal dimension that the resource argument often ignores. The Convention on the Rights of Persons with Disabilities, which most countries have ratified, commits states to providing persons with disabilities the same range, quality and standard of health care as others. Inclusion is not only a policy preference. It is an obligation.
Second-order effects
Carers carry the gap. When services are inaccessible, family members fill in by lifting, interpreting, advocating and coordinating. That burden affects their own health, employment and income.
Emergencies expose weaknesses. WHO has noted that persons with disabilities are more affected by health emergencies. When services are disrupted, those who already faced barriers are often the first to lose access.
Inclusion benefits others. Many adjustments designed for persons with disabilities also help older people, people with temporary injuries, parents with young children and people with limited literacy. Clear information, step-free access and flexible appointments make services better for everyone.
Workforce. Health professionals with disabilities remain under-represented. Their presence changes how services are designed, and inaccessible training environments keep them out.
What this means for different decision-makers
For health ministries, the priority is data. Including disability questions in health surveys and service records, with appropriate consent and protections, is the only way to see where gaps are. Payment systems can then be adjusted so that providers are not penalised for giving patients the time they need.
For hospital and practice leaders, a practical audit is within reach: walk the patient journey from booking to follow-up with people who have different disabilities, and fix what breaks. Procurement policies can require accessible equipment as standard.
For funders, disability inclusion should be built into health programmes from the start, with organisations of persons with disabilities involved in design and monitoring, rather than added as a separate project.
For clinicians, the habit worth building is to ask what adjustments a patient needs, and to consider whether a new symptom might have a cause other than the disability. That one question can prevent diagnostic overshadowing.
What to watch next
Watch whether national health information systems begin to record disability status routinely, so that gaps in screening, vaccination and chronic disease management become visible. Watch whether payment reforms recognise the extra time some patients need. And watch the involvement of organisations of persons with disabilities in health planning. Where they are at the table, services tend to change. Where they are consulted only after decisions are made, services tend not to.
Why “special needs” framing backfires
A final point concerns language inside health systems. Adjustments for persons with disabilities are often described as “special needs” or “extra support.” The framing sounds kind. In budgeting terms, it is dangerous, because anything labelled special or extra is the first thing cut when money is tight.
A more accurate framing is that adjustments are what it takes to deliver the standard service to a particular patient. A longer appointment for someone who communicates with an aid is not extra care. It is the same consultation, delivered in the time it actually takes. A hoist is not a special item. It is the equipment needed to examine a patient who cannot climb onto a couch.
When services describe adjustments this way, they become part of the core budget and the core definition of quality. When they are described as extras, they remain permanently optional, and permanently vulnerable. Words shape budgets more than we usually admit.
Organisations of persons with disabilities have been saying much of this for years. The gap is rarely a lack of knowledge about what to do. It is a lack of systems that make doing it routine, funded and measured, rather than dependent on the goodwill of an individual nurse or doctor on a particular day.
The takeaway
Health systems like to measure inclusion by what can be photographed: a new ramp, an accessible entrance. Those are necessary and overdue. But a person can roll through an accessible door into a consultation that is too short, with a clinician who attributes every symptom to their disability, in a system that never records whether they were screened.
The mortality gap will not close at the entrance. It will close in the consulting room, and in the payment rules that decide how much time that room is allowed to give.
What adjustment has made the biggest difference to disability-inclusive care where you work? Share it below.
