Analytical note on challenges in the rehabilitation system for people with visual impairments

Financial instability as a barrier to providing continuous services

One of the main challenges reported by Providers was a lack or instability of funding, especially for those who provide services at community level. Providers become dependent on receiving grant funds, which hinders long-term rehabilitation support, the retention of specialists and, consequently, the sustainability of services:

It’s difficult to get sustainable funding — that’s the main problem! The rest can be solved, but keeping a team and ensuring continuity of services without sustainable funding is impossible.

A small organisation, like ours, it goes from project to project. I see a flaw in this, let’s say, model, because we don’t have sustainability.

In addition, this creates unequal access to services between different socio-demographic groups because of the limited target audiences of grants or allocated state budgets, for example, assistance only for veterans or only for internally displaced persons. As a result, providers have to refuse rehabilitation to people who are de facto their target audience but de jure do not have the relevant supporting documents.

Those who were injured not as a result of the war don’t really understand where to turn, because now the focus is usually on veterans and the military. This is an urgent problem right now. There are just very many of them, and these people were already... They’re already somehow coping at least a little. Well, but this is a person, this is an injury. This, first of all, you understand, you can’t just leave the person alone at home now.

Without the support of such funding, some Providers keep their services stable by providing assistance on a voluntary basis. At the same time, this creates its own risks, in particular poor-quality assistance due to a lack of qualifications, or services stopping because of volunteers’ psychological exhaustion:

Even volunteers bring canes to hospitals. They try to teach them, but in many cases they help incorrectly…

The lack of funding also leads to problems with premises and material and technical resources: providing the heating needed to hold activities in the cold season, an inclusive entrance and a shelter, which is needed because of the war. The lack of shelters, heating and electricity significantly limits organisations’ capabilities, forcing them to suspend their activities and not hold events.

The main problem is that there are no safe locations even for holding some group activities. Evacuation is complicated, because there’s no shelter, and you have to evacuate several dozen blind people quickly...

The building has no heating, there’s nothing to pay for the heating with.

From 2002, the state provided institutional financial support to the all-Ukrainian public organisation Ukrainian Society of the Blind without competitive procedures. This support was cancelled in 2020 by Resolution of the Cabinet of Ministers No. 166 (in Ukrainian) “Certain Issues of Providing Financial Support to Public Associations of Persons with Disabilities”, and financial support for NGOs of persons with disabilities moved to a competitive format (opinion of the National Agency on Corruption Prevention).

On the one hand, this ensured equal conditions for all NGOs to obtain funding. At the same time, some Providers stress that, because of this, organisations providing specialised services for different types of functional impairments are forced to compete with each other for funding in communities, even though each group needs stable specialised support. The lack of stable jobs may also reduce young students’ interest in choosing this field as their profession.

The state makes organisations working with different nosological groups compete for the same money. Why this was done is not clear.

One possible way to solve this problem in communities is to create municipal rehabilitation institutions. Currently, Ukraine has one municipal institution at community level — the Kyiv Municipal Rehabilitation Institution “Kyiv City Centre for the Blind”. Geographical restrictions based on the registered place of residence may be an obstacle to accessing this type of institution, while establishing such centres throughout Ukraine could ensure the continuity of rehabilitation services. Such centres could include, in particular, special schools and educational and rehabilitation institutions, after their staff complete advanced training courses, so that they extend their services not only to children but also to adults. An alternative is to introduce narrowly focused competitions within the most common nosologies, in particular for vision.

During the project, the team interviewed specialists from 6 special schools in Kyiv, Lviv, Odesa, Kamianets-Podilskyi, Sloviansk (Donetsk Oblast, currently working online) and the village of Vyhoda (Ivano-Frankivsk Oblast). The Kamianets-Podilskyi special school is already a participant in an experimental project of the Ministry of Veterans Affairs and is ready to provide services to veterans. The other schools also confirmed that they have experience outside their regular teaching work with blind veterans who approached them for help individually.

Shortage of staff, quality control and standardised certification

Another challenge mentioned by Providers is a significant shortage of qualified specialists who provide services for people with visual impairments. This creates gaps in services and makes scaling up impossible. The war exacerbates the problem, as some specialists continue to leave the country. As a result, the workload on the remaining specialists increases, which can lead to psychological exhaustion and moving to other fields.

There aren’t enough people on the team. We’re working on setting up a full-fledged department.

A large share of people have gone abroad. So the problem with staff is quite common. Well, and the level of salaries in the public sector, you understand yourselves.

Historically, in Soviet times, rehabilitation activities for blind people were carried out exclusively by the Ukrainian Society of the Blind, as part of preparation for work at enterprises where more than 50% of employees were blind or partially sighted people. All regional organisations of the Ukrainian Society of the Blind reported that they currently do not provide professional rehabilitation services because of a lack of state funding. At the same time, the rehabilitation centre of the Ukrainian Society of the Blind in Kyiv sometimes holds rehabilitation camps for veterans when donor funding becomes available.

In the Soviet Union we had 83 plants and enterprises. We manufactured products according to the plan under state orders. After the transition to the “market”, many closed. Now 53 enterprises still remain.

In the medical field, the problem is aggravated by the complete absence of the topic of rehabilitation of blind people from the curricula of universities that train occupational therapists, physical therapists and social workers, although a few universities have already started adjusting their programmes.

The only systematic source of specialists is university programmes in the specialities “Typhlopedagogue” (a special education teacher for people with visual impairments) / “Defectologist” (a special education teacher). All lecturers of advanced training courses in Ukraine, both for occupational therapists and for typhlopedagogues, are people with a specialised education in “Typhlopedagogy”. This issue was covered in the study analysing the situation of people with visual impairments (T. Hrebeniuk, 2023), according to which Ukraine has an acute shortage of specialists for the rehabilitation of adults with visual impairments; in particular, there is no training of rehabilitation teachers or orientation and mobility instructors.

At the same time, specialists who already work in the health care and social policy systems are not trained to work with people with visual impairments, which may lead to services in hospitals being absent or of poor quality.

Unfortunately, in our country there isn’t a clear place where you can learn.

Specialists with diplomas but without knowledge — that’s our deepest problem.

This problem also applies to psychologists and psychotherapists. Psychological barriers are one of the most frequently mentioned challenges, as they affect all stages: the willingness to undergo rehabilitation, the acquisition of skills and adaptation in communities. Providers stress the need to revise the curricula of all specialists involved in the rehabilitation system for people with visual impairments.

Currently, advanced training courses for specialists are provided by, among others, the Ukrainian State Dragomanov University, the State Rehabilitation Centre “Podillia”, the all-Ukrainian civic union “Modern View”, the NGO “Trinity hub” and the charitable foundation “Foundation 03:00”. The experience of experts from these organisations could be used to create new components of educational programmes in higher education institutions.

Provision of incorrect information about vision rehabilitation at first contact in hospitals

Providers noted that their clients complain that specialists at the treatment stage are not aware of the options for further rehabilitation. Doctors sometimes spread false information about the possibility of restoring sight with the latest brain implant technologies, talking about research that has not been completed. As a result, blind people may get a false idea of the prospects for rehabilitation and treatment. The lack of the necessary information leads to significant delays in receiving services, affecting people’s psychological state, level of independence and motivation.

They don’t know where to turn, what process is supposed to happen next and what the end result is. That is, there’s no such path for a person who has lost their sight, written out, formulated in a rehabilitation plan, for people, it’s hard for them to get this information.

The absence or delay of specialised support at the acute stage after injury can also increase the risk of becoming completely dependent on others and increase the likelihood of injuries while moving around. A person may get used to unsafe or ineffective ways of moving around, which makes later orientation training with a cane more difficult.

And they walk the way they’ve got used to, that’s bad. Retraining is very hard, because they’ve already adapted somehow in their own way and that’s it.

Therefore, some Providers stress the need for a “first-contact service”, that is, support and counselling for people with visual impairments already at the early treatment stage.

The earlier you come in and the earlier you start showing all the possibilities, all the prospects, and introduce them, for example, on the “peer-to-peer” principle, to those same civilians, blind, independent, rehabilitated, military people who have already been through rehabilitation, the better. It really is better.

At the first stage there’s no such coordinator who could provide this information in the hospital... Now we have veteran support specialists working at hospitals, but they don’t know anything about blind people either, so they need to be trained.

Such counselling should also be carried out with the family, as the family can be not only a source of strong support but also a factor that slows down rehabilitation. The problem of overprotection and prejudice in the family was the second most discussed topic among providers of professional rehabilitation services.

The problem of why a person doesn’t orient themselves is the influence of the family. They don’t give them the chance to be independent. People don’t know, people are afraid. Well, very often a person won’t start walking with a cane because for some reason the family is against it.

Lack of support in communities and of a pathway for vocational adaptation

Providers highlighted the problem of employment as one of the critical obstacles to the comprehensive adaptation of a person with complete or partial loss of vision. The lack of active work with communities reduces awareness of professional opportunities both for the person and for businesses, educational institutions and the civil society sector.

They start believing in themselves, but where are they supposed to go to work? Very few options. And in most cases, I see, they start thinking about how they could run their own business.

The situation is more complicated for people who live in rural areas or have only secondary education, which narrows their employment options and increases the risk of social isolation:

Right now it’s very difficult to find work in a village and to agree with at least some business that they’ll take this person on.

Providers note the lack of a state plan for support during employment and of coordinated work with communities and businesses.

And without a clear state strategy we will never pull these people out of their homes and into work. The labour market doesn’t do it on its own, people don’t do it on their own. Only a clear state policy on integrating blind people into the labour market can do this.

Currently, various Providers deal with employment issues, in particular by providing additional training in pottery, massage or in-depth learning of adaptive software for working on a computer. For example, distance learning in programming for blind people is provided by the NGO “Practice of Innovative Experience”, and the charitable foundation “Foundation 03:00” ran a project to employ blind people as baristas.

Spatial barriers in communities and lack of inclusive design

Providers identify physical spatial barriers in communities and the non-universal design of public spaces, household goods and medicines as one of the challenges. Tactile paving, inscriptions and signs in public spaces, or medicines with Braille, are available but are often practically unusable. In addition, builders ignore the State Building Codes (DBN) on contrast, which is necessary for the safe orientation of people with residual vision.

From the point of view of accessibility for blind people, signs and everything else, it’s a sham. A great deal is incorrectly printed in Braille, the wrong size, printed mirror-image, missing words, missing letters, in the wrong place. […] But in reality you start reading — and it’s gibberish written there.

For example, they put those same bollards in the middle of the pavement. According to the regulations they’re grey, the same colour as the paving, a person with a visual impairment can’t see them.

Providers note that to overcome this problem, people with visual impairments need to be involved both at the stage of discussing building codes and during the approval of construction projects, so that they can actively test and check them.

You need to be able to feel the tactile paving with your foot. You need to be able to feel the tactile paving with your cane. And it’s not always like that.

Similar problems are observed in the area of digital accessibility, where government websites are not always adapted for people with visual impairments:

So, this very website “Accessible City” is not accessible to blind people, so if a person with a visual impairment wants to write that something there is inaccessible, they can’t do it, because the website itself is inaccessible to them.

Providers stress the importance of involving people with visual impairments and experts in the creation and testing of accessibility features, as well as strengthening monitoring and quality assessment.