Cloak of Invisibility: A Literature Review of Physical Disability in Ghana

This literature review surveys the state of current scholarship on physical disability in Ghana. The intention is to identify major themes and opinions relating to the challenges faced by Ghanaians with physical disabilities. After an extensive literature review, the authors selected 21 articles for inclusion based on the criteria that they had to focus on physical disability in a Ghanaian setting. Reviewing the articles revealed that most scholars have focused on the pervasive oppression of Ghanaians with physical disabilities. Six major topic areas emerged, including the experience of the disability rights movement from the 1990s to the present, the public perception of people with physical disabilities, the issue of families and abuse, the rights to education, challenges around employment and finances, and health care for disabled Ghanaians. This literature review presents these topics, discusses their implications, and makes suggestions for further research and action to improve human rights for Ghanaians with physical disabilities.


Introduction
The United Nations Convention on the Rights of Persons With Disabilities (2006) sparked a surge in research into disability rights across the world. In Africa, Ghana has been no exception as Ghanaian scholars have produced significant work on disability issues, especially since 2006. The literature has covered a wide range of disabilities, including physical disability, mental illness, and diseases such as HIV/AIDS. In the interest of narrowing this discussion, for this review, we have chosen to focus on physical disability. This important work relates to a large segment of the Ghanaian population, as existing research demonstrates that the physical disability rate for Ghana is currently between 3% and 4%, or between 650,000 and 860,000 people (Dassah et al., 2018;Kassah, 2008). There is a growing body of work relating to this population in Ghana. Of the resulting articles, the authors selected 21 which focus most strongly on the experience of persons with physical disabilities. In this review, six major topic areas emerged: the experience of the disability rights movement from the 1990s to the present, the public perception of people with physical disabilities, the issue of families and abuse, the rights to education, challenges around employment and finances, and health care for disabled Ghanaians. Throughout this review, general trends within these six topic areas are explored in detail.

History of Disability Rights in Ghana
The literature demonstrates that the disability movement of the 1990s was a time of major social change for persons with disabilities (PWDs) in Ghana. In 1992, the Ghanaian government amended the Constitution, after the country democratized, to provide access to basic rights such as education and accessible public spaces while transforming the political atmosphere into one in which PWDs and their advocates and care givers could more safely fight for their rights (Gavu et al., 2015;Mprah et al., 2014). Shortly thereafter, the government introduced a community-based rehabilitation (CBR) pilot program based upon welfare principles and funded internationally from 1999 to 2002 by both the United Nations and the Official Development Assistance (Kuyini et al., 2011;Metts & Metts, 2000). The program was a laudable effort to reintegrate individuals with disabilities into the community, but it failed to achieve its goals due to a lack of commitment by community members and government officials. As a result, international funding eventually dried up.
Despite the failures of the rehabilitation and reintegration programs rolled out during the 1990s, they served the important purposes of improving public discourse surrounding the social inclusion of PWDs and motivating disabled activists, the government, and civil society to take action for bigger and better changes. Eventually, the 1992 constitutional amendment was deemed unsatisfactory by PWDs, the public, and the government alike, as it did not cover all basic human rights (Gavu et al., 2015). This eventually led to the passing of the 2006 Persons With Disabilities Act. According to Gavu et al. (2015), the aim of the Act "was to fulfill a constitutional obligation of enacting laws to protect and promote the rights of people with disabilities" (p. 7). The Act also proposed that by 2016, PWDs would have the same access to various services as a non-disabled person would (Reynolds, 2010). Specifically, the Act outlined rights of PWDs to proper housing, equal employment and educational opportunities, access to public spaces and transportation, adequate medical care, and protections against abuse (Dassah et al., 2018;Dogbe et al., 2016;Ganle et al., 2016;Gavu et al., 2015;Kassah, 2008;Kassah et al., 2012;Reynolds, 2010). Overall, the passing of the Act was a meaningful step in the removal of barriers to social inclusion of PWDs within Ghana.
The Persons With Disabilities Act has been critiqued in the years since its implementation. One of the longest-standing issues is that of building architecture. Despite the Act's call for equal access to public spaces, inaccessible public buildings are consistently pointed out in the literature as a continued form of discrimination against PWDs (Dassah et al., 2018;Ganle et al., 2016;Gavu et al., 2015;Gregorius, 2016). A unique take on the reasons behind this inaccessibility is offered by Gavu et al. (2015), who note that public perception of PWDs suggests they "are incapable of making a meaningful contribution" to society (p. 6). As a result, PWDs are physically excluded from meaningful spaces. In addition to barriers in the built environment, the general lack of enforcement of the provisions of the Persons With Disability Act is also a common theme. The Act is applauded for its conceptualization of basic human rights for all; however, these rights are often not implemented properly, especially concerning PWDs facing multiple oppressions in a way that is similar to those who are incarcerated (Dogbe et al., 2016;Gavu et al., 2015;Kassahe et al., 2012;Sossou & Yogtiba, 2016).
Still, identifying the exact barriers to the proper implementation of the Persons With Disability Act remains unclear. Speculation within the literature suggests that lack of public education regarding both the Act and disability rights in general may lead to apathy about the subject (Gavu et al., 2015;Naami et al., 2012). For example, in their study on the implementation of the Act in a Ghanaian university, Gavu et al. (2015) found that 62% of students with disabilities interviewed did not know that the Act existed. Notably, Sossou and Yogtiba (2016) also suggest that a lack of government commitment both socially and economically may send a message to the public that the progression of disability rights is not a priority. Nevertheless, to date there appears to be no clear suggestion within the existing literature regarding possible solutions to implementation barriers for the Persons With Disability Act.

Current State of Disability Rights
Disability advocacy and improvements in public perceptions. Some of the recent literature suggests that the passage of the Disability Act has led to improvements in public attitudes toward PWDs (Reynolds, 2010;Sossou & Yogtiba, 2016). When asking questions about disability, Reynolds (2010) found that most people in her sample could articulate that physical disability had spiritual rather than medical causes. Due to this understanding, most interviewed acknowledged that PWDs should have basic rights; however, they do not necessarily believe that these should be the same rights as people without disabilities. While this is a small improvement, Reynolds (2010) argues its significance lies in the recognition of inherent rights for PWDs. Overall, Sossou and Yogtiba (2016) suggest that "public education and knowledge, easier access to information, and greater national visibility of productive people with disabilities" have led to an improvement in the social situation of PWDs in Ghana (p. 27).
These improvements have been driven by the actions of PWDs themselves. The literature shows that many Ghanaian PWDs actively resist oppression and marginalization, which continues to be a major issue in Ghanaian society, in important and unique ways. For instance, Bourgeois' (2011) study on self-activism through sports demonstrates an interesting and effective strategy used by athletes with disability to fight for recognition of their humanity. In her interviews, Bourgeois (2011) found that disabled Ghanaians use sports to demonstrate their abilities in the public arena, thereby earning respect for their talents and reducing stigma. Positive attitudes toward the athletes carry over into daily life, as outsiders notice that the PWDs are capable of completing "regular" activities and tasks. As a result, people are more willing to speak and interact with PWDs. Individuals with disabilities self-advocate for their rights, resisting oppressive attitudes and promoting social inclusion (Bourgeois, 2011). As a result, sports become a vehicle for political activism surrounding disability rights in Ghana.
Social exclusion and stigma. Despite acknowledging some improvements, the literature generally paints a picture of persistent stigma, oppression, and a lack of human rights for Ghanaians with physical disabilities. Also, most of the studies report that human rights for people with disabilities are still not effectively enforced today, with poor government support, little commitment from non-government agencies, and few legal protections for PWDs in vulnerable situations such as prison (Dassah et al., 2018;Dogbe et al., 2016;Ganle et al., 2016;Gavu et al., 2015). Within this group, the literature reports that more women than men are physically disabled, and that women and children with disabilities are more severely disadvantaged than men (Badu et al., 2016;Kassah et al., 2014;Naami, 2015;Naami et al., 2012).
Barriers to human rights are reinforced by oppressive public perceptions toward disability in Ghana, which continue to permeate the dominant discourse. Ghanaian spirituality is currently informed by a mix of Christianity and traditional religion (Kassah, 1998). Spiritual beliefs suggest that physical disability is a punishment from God for the person's, or their family's, sins, and so it is deemed worthy of shame (Gregorius, 2016;Kassah, 1998;Naami et al., 2012). Due to the shame attached, an individual with a disability is also usually considered a burden on their family with nothing to offer (Kassah, 1998;Naami et al., 2012). There is a disconnect in that PWDs expect independence, while non-disabled people perceive almost total dependence due to the dehumanizing worthlessness attached to physical disability. As Kassah (1998) points out, the stigma involved is not exclusive to the individual experiencing disability but can apply to anyone associated with the stigmatized person. This includes family members and caregivers.
Furthermore, the belief that physical disability is a curse is prevalent enough in Ghanaian society that a trend emerged in existing literature regarding the unmarriable qualities of a person with disability. In more than one paper, Kassah (1998Kassah ( , 2008 notes that people will actively avoid marrying someone with a disability or with a family history of disability in their family due to the perception of a curse. If a partner discovers there is history of disability post-marriage, or a partner becomes physically disabled during marriage, it is considered reasonable grounds for divorce (Kassah, 1998(Kassah, , 2008Mprah et al., 2014). However, sufficient grounds for divorce do not rest solely on the assumption of a curse. If a woman becomes disabled during marriage, she is seen as asexual, and consequentially incapable of bearing children or performing motherly roles (Naami et al., 2012). Once perceived as unable to fulfill traditional female roles, she is considered unmarriable. Also, the perception of people with physical disability is that they are deserving of sympathy rather than respect (Naami et al., 2012). This dehumanizes the person and puts them in the position of the undesirable other, making them unmarriable to the greater society.
To sum up, despite improvements since 2003, the literature shows that negative public attitudes toward persons with physical disabilities continue to make them one of the most oppressed groups in Ghana. PWDs violate "normal ways of relating and behaving," and as such are left out of public spheres such as education, medical care, and employment due to stigma and unwillingness to understand (Kassah, 1998(Kassah, , 2008Kassah et al., 2012, p. 692;Mprah et al., 2014).
The authors realize that the negative perception of PWDs often leads to widespread poverty, exclusion from quality health care, abuse, fewer employment opportunities, lower levels of education, and general social exclusion, each of which is discussed in the sections below.

Abuse and Social Exclusion: PWDs and Caregivers
Abuse and social exclusion of PWDs. If people with physical disability are dehumanized as unworthy of respect, this means they are not entitled to humane treatment. In Ghana, the literature shows that women and children are especially vulnerable to abuse (Kassah et al., 2012(Kassah et al., , 2014. Importantly, Kassah et al. (2012), the main authors on this topic, note that abuse of these populations is widely known but not sufficiently studied. Consequentially, there is little literature on the topic. However, due to its serious nature and the potential impacts on abuse victims, this literature is discussed in this section.
Among children, Kassah et al. (2012) found that "social, capital, physical, and emotional" abuse was most common (p. 695). Social abuse is present in both neglect and isolation by parents, who often attempt to distance themselves from the stigmatized child for fear of ridicule from the wider community (Kassah et al., 2012). In addition, both capital and physical abuse are spiritually driven. Physical abuse is seen as a means of driving the evil out of the child, while capital abuse is sometimes used by parents and spiritual leaders to end the child's life, eliminating evil and sending them back to the gods (Kassah et al., 2012). Although murder is a criminal offense in Ghana, capital abuse perpetrated on physically disabled individuals is often socially encouraged by pressure to conform to social norms (Kassah et al., 2012). Finally, neglect and physical abuse contribute to emotional abuse, as the child is deprived of the emotional nurturing required for healthy development (Kassah et al., 2012). For the most part, abusive actions toward individuals with physical disabilities are heavily entrenched in spiritual, cultural, and social norms.
Similarly, abuse toward women with physical disabilities is driven by values, in this case toward gender norms. In modern-day Ghana, most women have traditional nurturing roles, such as bearing children and taking care of the house (Kassah et al., 2014), and some women work from dusk to dawn to provide for the home. Women with disabilities are seen as incapable of taking on these roles, as well as incapable of having a healthy sexual life, and so marrying them is considered socially unacceptable. According to Kassah et al. (2014), if a man falls in love with a woman with disability, the stress of the taboo relationship often leads to abuse spurred on by power and control. Partners have been reported to carry out physical and sexual abuse, such as rape or unwanted touching, if a woman is seen as contravening traditional norms, as well as verbal abuse by calling their partners disparaging names (Kassah et al., 2014). These actions are performed as a way for the non-disabled partner to feel validated in society again. Furthermore, women with physical disability are also more exposed to social abuses than men, such as lower education levels, name-calling by strangers on the street, and police refusal to help abuse cases (Kassah et al., 2014).
Abuse and social exclusion of PWDs and caregivers. Due to the stigmatization of PWDs, family members and caregivers often feel socially excluded. This can lead to frustration and exhaustion, which may have dire consequences for both themselves and the individuals in their care (Opoku et al., 2017). The stress of marginalization can manifest in several ways for both the family member and the individual experiencing disability. In dominant Ghanaian culture, an individual's social support system is very important. However, in the lives of person with disabilities, social supports do not seem to be applicable due to stigmatization and dehumanization (Opoku et al., 2017). When there is no public or community support system, support of the individual with disability falls to the family. Yet oftentimes the family abandons them too, as most Ghanaian families are ashamed of the individual and fear stigmatization (Opoku et al., 2017;Zuurmond et al., 2018). Many families still struggle to understand the innate human worth of the individual experiencing disability.
When families do decide to take on the role of caregivers, it is often no easier, as multiple social barriers exacerbate the vulnerability of both the family and the individual with disability. Caregivers are usually inadequately supported by social services, as many families have little access to financial and educational resources to learn about how to take care for the person. This lack of support often leads to impatience caused by misunderstanding of the disability (Kassah, 1998;Opoku et al., 2017;Zuurmond et al., 2018). Lack of social supports for the caregivers also exacerbates this problem, as frustration is compounded by feelings of social isolation and loneliness (Opoku et al., 2017;Zuurmond et al., 2018). Zuurmond et al. (2018) note that this often leads to caregivers experiencing physical and emotional exhaustion, extreme stress, anxiety, and depression.
When caregivers experience intense emotional and physical strain, this can contribute to the abuse of vulnerable subpopulations as previously described. Strain can negatively affect parenting quality, as parents may take their stress out on children through physical, emotional, or verbal abuse (Zuurmond et al., 2018). In addition, social isolation can make caregivers feel powerless, which may lead some caregivers to "withhold, misuse or delay support needed by care recipients as a way of gaining control and power" (Kassah et al., 2014, p. 666). However, Kassah et al. (2014) caution against rationalizing abuse on the grounds that caregiver stress can lead to victim blaming, and as such may perpetuate abusive cycles if discussions surrounding this topic are not carefully handled.
Despite the fact that caregiver stress has a multitude of negative consequences for both the caregiver and the care recipient, the authors found only one peer-reviewed article that addressed ways to support caregivers. Zuurmond et al. (2018) report on their experiences running a support group and training program to help caregivers learn how to best assist individuals with physical disabilities. During the program, the authors found that most family members do not understand the individual's diagnosis and lack objective explanations in non-stigmatizing language. As a corrective, the authors found that supporting the caregivers through access to non-discriminatory descriptions helped reduce stress, as the caregiver was better able to understand the social location from which the person with disability experienced daily life. This understanding led to reduced anxiety and increased patience (Zuurmond et al., 2018). Moreover, the support group helped caregivers feel that they were part of a community again, which helped reduce feelings of social isolation. Zuurmond et al.'s (2018) study is significant, as it demonstrates the important role that caregiver support plays in the quality of life of both caregivers and care recipients.

Education
Education is crucially important to all Ghanaians, but the literature points to significant barriers to schooling for PWDs. First, several authors report that many families see the education of children with disabilities to be a waste of resources, often because of the social perception that PWDs are incapable of contributing to society (Gavu et al., 2015;Kassah et al., 2014;Opoku et al., 2017). Due to this perception, people with physical disabilities are often physically excluded from educational spaces. Despite the Disability Act's call for all public buildings to be accessible, presently most educational architecture is still inaccessible. This includes lack of accommodation both outside the buildings in the form of ramps, as well as inside lecture halls, thereby demonstrating that physical accessibility remains a huge barrier to education for those with physical disabilities (Gavu et al., 2015;Gregorius, 2016). Second, stigma and negative attitudes of non-disabled Ghanaians make the social environment difficult, as PWDs feel isolated and socially excluded, and they refuse to attend school as a result (Gregorius, 2016;Opoku et al., 2017). This demotivating factor can be strongly internalized. Using a unique narrative research approach to this topic, Gregorius (2016) found that social isolation at school led to low self-esteem, internalized stigma, and the belief that they deserve to be excluded as they blame themselves for failed integration with peers. These feelings may cause people with disabilities to drop out of school earlier than non-disabled individuals, which often creates higher illiteracy rates and lower levels of employable skills among this community (Opoku et al., 2017).
Other notable barriers to education include gender discrimination and financial difficulties. According to Naami (2015), education levels among PWDs are generally higher for men than women. Bourgeois (2011) speculates that this imbalance is due to the intersecting oppression experienced by women for being both female and disabled, leading to double discrimination. Nevertheless, for both men and women with disabilities poverty is an issue, and so they often cannot afford the same levels of education as non-disabled people (Gavu et al., 2015). In general, the literature demonstrates that both structural and societal barriers prevent people with physical disability from accessing quality education, which may have consequences for future employment and income generation.

Employment and Finances
Often tied to lower levels of education, high unemployment rates are one of the biggest issues facing people with physical disabilities (Naami, 2015;Naami et al., 2012). Even if they can find work, it is usually seasonal and poorly paid, and it does little to reduce the high poverty rates among PWDs (Naami, 2015;Naami et al., 2012). Employment also does little to improve social exclusion, as PWDs face pay discrimination, harassment from co-workers who assume they are incapable, and verbal abuse by employers.
Authors writing in this area cite several reasons for unemployment among PWDs, including employers' failure to recognize the potential in people with disabilities, employers' fear of the perceived spiritual evil associated with physical disability, and the high costs of disability accommodation (Naami, 2015;Naami et al., 2012). Of these factors, stigma toward the economic potential of PWDs is particularly significant. Ghanaians with physical disabilities generally want to work, but the "economic productivity of persons with disabilities is often perceived as insignificant" (Mprah et al., 2014, p. 31;Naami et al., 2012). This situation is worsened by structural barriers to employment for PWDs, which include scarcity of employable skills programs for professional development and lower levels of education (Naami et al., 2012). In addition, Naami et al. (2012) point out that people with disabilities are excluded in general policy making, which means they are often left out of employment policies at both national and local levels. This is significant as it means that companies are not mandated to include people with disabilities, hence contributing to structural barriers to employment.

Begging as Income
Employment discrimination has led many PWDs to search for alternative sources of income, with the most prominent being begging on the streets (Bourgeois, 2011;Kassah, 1998Kassah, , 2008Naami, 2015;Opoku et al., 2017). Begging is both illegal and fraught with perceptions of immorality; however, it persists because economic independence can increase an individual's social and cultural status in Ghanaian society (Kassah, 2008;Mprah et al., 2014). In effect, people with disabilities use begging as a way to work toward eventual social inclusion. The government has tried to eradicate begging through both criminalization and welfare approaches, such as providing financial support, but neither has stuck as this does not give people with physical disability the economic independence for which they strive (Kassah, 2008).
Aside from economic independence and social inclusion, there are numerous other reasons that keep begging a prominent source of income for PWDs. To begin with, the lack of employment avenues as previously outlined leaves many people with disabilities in poverty (Kassah, 2008;Naami, 2015;Naami et al., 2012). As a result, individuals start begging to be able to afford basic needs such as food, housing, and necessary medical equipment for their disability. In addition, many people with disabilities have found begging to be more lucrative than the menial employment avenues that are traditionally provided to them. Kassah (2008) found that some individuals who participate in begging make up to 40,000 Ghanaian cedis (equivalent of 40 new Ghana cedis or US$8) daily, versus the average daily income of 19,000 cedis (19 Ghana cedis or US$3.8). Finally, many individuals have identified begging as a confidence-builder. Some people with disabilities view begging as a legitimate form of work in which they gain both financial rewards and freedom from dependence on others (Kassah, 1998(Kassah, , 2008. Another article states that begging also demonstrates resilience, as individuals experiencing disability are being innovative and solutionoriented in the face of widespread oppression. The authors also noted that begging has the potential to overcome poverty and to gain entry into other work opportunities, such as self-employment if they have the necessary capital (Opoku et al., 2017) though this is rare. Although these positives do not show up in a great deal of the literature, they are worthy to note as they offer an alternative view on the subject of beggars.
On the contrary, it is important to note that, as many of our authors report, begging in Ghana generally is not praised but rather criticized and stigmatized, even within the community of PWDs. For example, Bourgeois (2011) found that PWDs who play sports use this skill to separate themselves from beggars, whom they consider inferior and unworthy of association. For this reason, although it is a prominent source of income, not all within the disability community engage in, or even approve of, begging on the street. Stigma toward begging is prominent among the non-disabled community as well, leading most of our authors to recommend solutions for reducing it and finding alternatives for PWDs. Throughout the literature, there is a call for government support of increasing access to capital for people with physical disabilities (Kassah, 2008;Naami, 2015;Naami et al., 2012). Multiple authors suggest that loans and grants specifically for start-ups by individuals with disabilities may help reduce the number of beggars, as they will more easily be able to obtain self-employment (Kassah, 2008;Naami, 2015;Naami et al., 2012). Notably, Naami (2015) also recommends public education forums focusing on the capabilities of PWDs to demystify PWDs in the workplace, which may lead to increased employment and decreased begging. On a more general note, there is a push for attitude changes toward people with disabilities in the workplace (Kassah, 2008;Naami, 2015;Naami et al., 2012). The authors realize that none of the literature reviewed explored attitudinal changes in society toward PWDs. Until this is further explored, there is the indication that begging will persist among Ghanaians with physical disabilities.

Gender Issues
Unemployment and poverty affect people with disabilities more than the general population; to compound this, within the disabled population, women face more discrimination and higher unemployment rates than men (Bourgeois, 2011;Naami, 2015). This double oppression leads to women being especially unlikely to find work (Naami, 2015;Naami et al., 2012). When women are employed, they usually experience lower pay due to the perception that they are a pointless investment because they are less capable than men (Naami et al., 2012). According to Naami et al. (2012), this stereotype is often internalized by women after years of discrimination and it can manifest in two ways. First, women with disabilities lack the self-confidence to apply for jobs and instead remain unemployed. Second, women with disability tend to use pre-emptive aggression as a self-preservation tool, leading to the stereotype that women with physical disabilities contribute to a hostile work environment. Either way, the result is an increase in poverty and unemployment among women and a significant gender gap in employment driven by discrimination.
Breaking down employment sectors, Naami (2015) reports that women are often overrepresented in the fields of production and sales, while men are overrepresented in the service field. Significantly, all of these sectors are relatively unskilled. For both genders, there is a lack of disability representation in managerial positions, which speaks to the limited opportunity allowed to people with disabilities even when they are employed (Naami, 2015). This imbalance reflects a lack of skills and training opportunities for Ghanaians with physical disabilities. Employment of an individual with disability does not automatically mean equity if they do not have the same opportunities for professional growth as a non-disabled person. The literature calls for access to employable skills programs for PWDs, especially for women, to empower their capacity in the job field (Naami et al., 2012).

Health care
Access barriers. According to Dassah et al. (2018), access is a key measure in the success of a health care system. Nevertheless, there is no clear definition in the literature about what constitutes reasonable levels of access, although the authors suggest that affordability, acceptable service providers, levels of accommodation, timeliness, geography of facilities, and awareness of available services are the most important elements. In Ghana, one of the greatest barriers is remoteness from facilities for PWDs in rural areas, who have the most trouble accessing health care because of the uneven coverage of institutions across the country and the lack of health care providers in rural areas (Dassah et al., 2018). That means that many PWDs must travel to major cities for health care, but most cannot afford to pay for transportation (Ganle et al., 2016).
Affordability in general has been identified as another barrier to health care for PWDs. In 2003, the National Health Insurance Scheme (NHIS) was introduced in an attempt to help impoverished and marginalized people with disabilities pay for health care-related costs (Bourgeois, 2011;Dassah et al., 2018). However, the current literature critiques the NHIS for its unclear criteria on who is considered disabled and what is considered impoverished (Bourgeois, 2011;Dassah et al., 2018). Due to the lack of clarity, not as many people qualify as expected and there appears to be no other significant form of financial help for individuals with physical disability.
When it comes to service providers, general trends have shown that most people with disabilities face discriminatory attitudes from health care professionals (Badu et al., 2016;Ganle et al., 2016). This is discussed in more detail in the next section; however, it is important to note that discriminatory attitudes form an access barrier due to poor disability training for health care students (Badu et al., 2016;Ganle et al., 2016). As with the caregivers described above, poor training leads to poor understanding of physical disability, and therefore stereotypes and frustration tend to permeate service provider attitudes. Consequentially, PWDs become reluctant to seek out health care (Badu et al., 2016;Ganle et al., 2016).
Finally, the supply of medication and hospital beds is also an issue in Ghana. Pharmacies are often sold out of medication for those coping with painful disabilities, and there are not enough beds in hospitals for those needing inpatient treatment (Dassah et al., 2018). This affects treatments and leads to long wait times for crucial services needed by those with physical disabilities. Generally, the literature provides evidence that Ghana's health care system is not yet fully welcoming to people with physical disabilities.
Health care provider attitudes toward people with disabilities. As briefly mentioned, many people with physical disabilities experience discriminatory or oppressive attitudes from service providers when accessing health care. While there is not a great deal of literature on this subject, it is important to note as access to health care is a basic right, and the dismissal of this group by health care providers is a direct violation of this right. For instance, in a study on health care provider attitudes toward physical disability (including hearing and visual impairment), Badu et al. (2016) report that there is support among health service providers for sterilization of people with disabilities. This support relates directly to the stigma and lack of education surrounding the capabilities of this community. Giving medical students the opportunity to participate in disability training, along with practical experiences working with people with disabilities, may help demystify PWDs and make health care providers more comfortable working with physical disability (Badu et al., 2016).
Another significant issue stemming from stigmatization is the impatience of health service providers when working with physical disability. Badu et al. (2016) point out that there are too many patients and not enough practitioners, meaning that practitioners are overworked and do not feel they have enough time to spend with people with disabilities. This lack of time leads to frustration toward these individuals if they move at a slower pace. In addition, due to stereotypes about the economic incapability of people with disabilities, their health care may not be prioritized by busy service providers as it may be seen as a waste of resources (Dassah et al., 2018;Mprah et al., 2014). More research is needed into how to improve health care provider attitudes toward people with physical disability to protect their human rights.
Sexual and reproductive health. The subject of sexual and reproductive health among the population of physically disabled arose numerous times in the literature. Among the general public, there is the perception that people with physical disabilities are inherently asexual, a label that is applied to both men and women alike (Bourgeois, 2011;Ganle et al., 2016;Mprah et al., 2014). Neither men nor women with disabilities fit the traditional gender norms of femininity or masculinity; instead, they are seen as having no sexual potential at all (Bourgeois, 2011). As a result, they are often excluded from sexual and reproductive health services. One of the biggest exclusions is in access to information for people with physical disabilities. Health care providers are generally not educated on disability-specific medical advice when it comes to sex or reproduction (Ganle et al., 2016;Mprah et al., 2014). For example, Ganle et al. (2016) reported the case of a woman who used a wheelchair who was told by health care providers to walk every day when she was pregnant, advice that she obviously could not heed. In addition, information about sexually transmitted infections and contraception is not readily available to PWDs based on the assumption that they do not have sexual needs (Mprah et al., 2014;Owiredu et al., 2015). Situations such as this lead people with physical disabilities to fend for themselves when it comes to their sexual and reproductive health.
A unique viewpoint on this subject was presented by Mprah et al. (2014), who noticed that most health care policies on sexual and reproductive health standards omit physical disability altogether with no clear reason why. The authors speculate that this may be due to the fact that public policies reflect social values, and as people with physical disability are marginalized in the wider community, this marginalization may be mirrored in their omission from health care policies. Nevertheless, Owiredu et al. (2015) found that rates and prevalence of sexual dysfunction are similar in both disabled and non-disabled communities. While this is a specific statistic, it is significant because it demonstrates a need for sexual health policies and practices applicable to the community of physically disabled. In general, the literature reveals a call for reform in this policy area (Ganle et al., 2016;Mprah et al., 2014).

Conclusion
Overall, the authors' survey of the literature shows that people with physical disabilities in Ghana are still in a precarious fight for basic rights. Although the passage of the Persons With Disability Act in 2006 was a meaningful step in the right direction, there is disagreement within the literature regarding whether this has improved the situation for individuals experiencing disability. While some authors state that the social situation of PWDs has improved since the implementation of the Disability Act (Reynolds, 2010;Sossou & Yogtiba, 2016), most others argue that people living with disability are still widely discriminated. In the public sphere, stigma and discrimination occurs in key areas of Ghanaian society including education, employment, and health care. This extends to the private sphere as well, where PWDs are often socially excluded and abused by family members. In response, most authors agree that better disability training for the public, health care providers, teachers, and caregivers alike may help to demystify people with disabilities and create positive attitudinal changes, thereby increasing social inclusion and opportunities for those involved. For this to occur, further research is needed into what this training would look like, and how widespread attitudinal changes could be. Unfortunately, the authors found nothing in the literature addressing the question of implementation of policies to reduce barriers to social inclusion as mandated by Ghana's Disability Act.
Consequently, more research is needed into how to overcome barriers so that the Disability Act can function to its full potential in enhancing disability rights. Even so, this review has revealed that Ghana's disability movement has made substantial progress since the 1990s through continued efforts by governments, activists, and researchers, and through the increased willingness to include PWDs in policy decisions affecting their well-being. If this can be sustained, then the advancement of disability rights in Ghana will continue to move in an inclusive direction.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.