The general (national) policy with respect
to disabled and elderly people
Heart – Line C – Type of SDS – SwitzerlandPart I : A general description
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PRELIMINARY R EMAR K
The following information mainly concerns children and adults because they are covered by the
Swiss Disability Insurance (ASSURANCE INVALIDITE). The actual State Pension Scheme for Elderly
and Surviving (Assurance Vieillesse et Survivant) is progressively taking more care of the expenses
dedicated to RT.
The 1st January 1959, the Federal Council, at the occasion of the 9th. revision of the “State Pension
Scheme for Elderly people and Surviving” (AVS), decided to increase its financial support with regard
to the products of the Rehabilitation Technology line. Since then, the list of the concerned approved
RT products has been being progressively enlarged. The applied rule is the following : when people
reach the age to go into retirement, they generally have behind them a full professional life during
which, they have put aside some money in reserve, in anticipation of their old age. The law has
foreseen, from the beginning, to count on the future pensioners’ personal financial participation in
this kind of foresight. Anyway, in case of hard financial difficulties, supplementary welfare benefits
can be granted.
1.1. The general (national) policy with respect to disabled
and elderly people
The actual attitude towards integration is
- to try, with the help of every kind of means, to restore the disabled person’s earning
capacity and to enable him to play an active role in the society;
- when the impairment or the handicap is not allowing integration, to contribute to provide
the disabled for means allowing him to live and to reach a certain quality of life.
To reach the above-mentioned objectives, the following main structures exist:
- about 150 special schools, mainly privately organised, but financially supported by the
OFAS, county budget and donations
- different professional training centres (about 10)
- about 25 social and legal consultants (private or state)
- 5 rehabilitation hospitals (BASEL / ZURICH / NOTTWIL / GENEVA / BELLIKON)
- etc..
Four main “steps” compose the global Swiss approach to finance device and equipment
delivery :
1.The Federal Social Insurance Office (Office Fédéral des Assurances Sociales / OFAS). The
Federal social Insurance Office corresponds to the main service provider. The OFAS
(AI + AVS) is financially supported by both an individual contribution of the employee
(5.05 % of the salary) as well as a participation of the employer (5.05 % of the salary
paid to the employee). The OFAS is acting at the FEDERAL level; it performs the
legislative part. At the executive level, each of the 26 Swiss counties has a “Federal
Disability Insurance Office”. Full detail about these offices is described further.
2.The National Swiss Insurance in case of Accidents, CNA (Caisse Nationale Suisse
d’Assurance en cas d’Accidents / CNA) is a nation-wide organisation obligatory for
every Industrial company. This means that each employee of an industrial firm is
automatically insured and therefore, member of the CNA. In case of an accident, and
during the first 720 following days, the CNA will cover all the costs linked to the
rehabilitation process, including the necessary technical aids the patient (insured)
needs. After those 720 days, the patient will no longer be considered like a
“rehabilitable” person, and then will be taken in charge by the FEDERAL SOCIAL
INSURANCE OFFICE (OFAS).
For non industrial companies (for instance offices), the insurance of the personal is also
obligatory but must not be the CNA. This means the employee can be insured by any
private insurance company providing the same kind of service.
3.Private insurance: In the field of Technical aids service delivery, private insurance are
nearly not engaged, if compared with the above-mentioned structures. Their
interventions therefore will not be described in this paper. For medical cares, a private
health or accident insurance will cover the corresponding costs during a maximum of
720 days. After that delay, the patient is “transferred” to the OFAS (AI).
4.Private charity organisations: For historical and legal reasons, the federal social system
does not cover all needs for RT. The costs related to a so-to-say “comfort” (for
example an adapted computer to allow a quadriplegic person to write letters to his
friends) are not completely or totally covered as well as the ones for research and
development for RT. Private charity organisations, financed by private donations,
inheritance, national or local collections, contribute to R&D, provide holidays
structures, and propose RT when the official structure does not take in charge totally
or partially the corresponding costs. Many times, private organisations take the
initiative of a new kind of structure or services. When the usefulness of the new
service is demonstrated, the official structure totally or partly supports the inherent
costs (this is for example the case of the Swiss Foundation for Electronic aids, still a
private organisation, but largely financially covered for all its activities related to Swiss
disabled RT user). R&D activities are always financed by other sources like
grants/donations .
I.2. History of the Service Delivery since 1945
In 1947, creation of a Federal Social Insurance Office (OFFICE FEDERAL DES ASSURANCES
SOCIALES) for both, handicapped and elderly people. This is a Federal organisation. Every
Swiss citizen professionally active must pay, each month, a percentage of his income
(5.05%) as well as his “employer” (also 5.05 %). The Acts of this insurance are federal. The
application of them are made independently, mainly, in each of the 26 counties. All Swiss
citizens are concerned. The Federal Social Insurance Office (OFAS) is divided into to parts : -
Federal Disability Insurance (for the persons in age of having an active life, i.e. 65 years old
for men and 62 for women), - the State Pension for Elderly and Surviving (AVS) for the old
age. The AVS is financed by a percentage (included in the 5.05% (as mentioned above) of
the monthly income of each of the active workers.
I.3. Description of the system
Rehabilitation measures are governed by the Federal Disability Insurance Act (LOI FEDERALE
SUR L’ASSURANCE INVALIDITE/LAI) of 19 June 1959. The main body of this law is
concerned with such measures since the first priority is to do everything possible to restore
the disabled person’s earning capacity or at least to increase it in such a way as to enable
him to keep himself and his family. Every Swiss citizen benefit of this insurance. The
disability must be recognised by a medical doctor.
Since 1959, many modifications of this law have been made in order to increase the “quality
of life”, independently of the fact that socio-economic integration is made or possible.
Special provision has been made in favour of educable minors who, as a result of a
disability, are unable to attend a state school or cannot be expected to attend one and in
favour of minors with no or little capacity to assimilate elementary school disciplines.
I.3.1 A general overview
I.3.1 a) A brief description of the scope of the system (i.e. who benefits)
In Switzerland the insured has a right to medical benefits not mainly designed to treat
the disorder as such but which are directly necessary for vocational rehabilitation and
which are likely to result in a major and lasting improvement in earning capacity or to
safeguard it from a marked reduction.
The Federal Disability Insurance scheme provides aids within the limits laid down by
Article 21 of the Disability Insurance Act in pursuance or the Order on the provision of
aids under disability insurance (OMAI) issued by the Federal Department of the
Interior. In principle, the insured persons who need aids to carry on a gainful activity
or to do usual work, are entitled to aids. Insured people who, on account of their
disability, need expensive appliance to move about, establish contacts with their
surroundings or develop their personal independence, are entitled to such aids
regardless of their earning capacity. This Order also contains additional provision
concerning the supply of aids, contributions to the cost of adapting appliance and
homes necessitated by the disability and contributions to the cost of special services
required by the insured in lieu of an aid. It is important to note that RT products paid
by the OFAS remain property of the insurance. They are at the disposal of the disabled
as long as he needs the aids. If, for a reason or another, the person does not use it
any more, the aid will be recycled/revised. After having being controlled, the aid will be
put again at the disposal of another user.
I.3.1 b) T he p resence o f s ubsystem s (e.g. are there different systems based on differences in
disabilities, ages, cause of disability, type of technology, etc. ?)
In the few cases the Federal Social Insurance is not financing the RT products (like a
television set for someone who needs an environmental control, a computer for an
adult who does not need it for professional reasons or an augmentative communication
aid), subsystems like private insurances or private charity foundations (for instance, for
physical or mental handicap, deaf a.s.o.), partially or totally, will take care of the costs
inherent to the disability.
I.3.1 c) D ifferent levels in the s ystem (e.g. national, regional, local) and the responsibilities at these
levels.
All RT companies are involved in service delivery. Mainly, RT delivery of RT products
and services is organised in this way:
Information : happens through one permanent large Swiss exhibition centre (the EXMA,
in Oensingen - located in the middle of Switzerland, run by the FSCMA) or locally by RT
companies as well as by large organisms like Pro Infirmis, which is present in each of
the 26 counties (Pro Infirmis is a nation-wide private organism (mainly financially
supported by the OFAS) which consults disabled regarding all aspects of the Swiss
social system, including some very basically aspects related to RT. Pro Infirmis employs
about 300 people, most of them are social assistants).
Testing and training are made by the user, before definitive prescription: with the
support of RT companies or local organisms supported by private charity organisation
and official organisms like FSCMA (Fédération Suisse de Consultation en Moyens
Auxilliaires, FSCMA).
Prescription: after the testing and training period, official request is made and submitted
to the OFAS by a medical staff or a social local organism (Pro Infirmis, for example).
I.3.2 Legislation
The following legislative texts include general provisions for the vocational and occupational
training of disabled persons:
- Federal Law on military insurance of 20 September 1949
- The Federal Employment Injury Act (1981)
- The Vocational Training Act (1978)
- The Federal Employment Act (1951)
- The Federal Disability Insurance Act of 19 June 1959
All these laws are aimed at: integration, as far as possible, of disabled people in the society.
(house adaptation, work place adaptation, study to learn a new and more adapted
profession). Quality of life is also considered. In other terms, even with sever disabled
people, those laws provide support (home adaptation, communication) for persons having
no chance to be professionally integrated again.
I.3.3 Organisations involved in Service Delivery
I.3.3 a) Financing, funding and purchasing
Federal Disability Insurance (AI); Swiss National Insurance in case of accident (CNA);
private charity organisations like : Swiss MS society; Swiss para foundation; Swiss CP
foundation; Pro Infirmis; Pro Senectute. These private organisms are composed both
by disabled and not disabled people.
I.3.3 b) Intermediaries: the professionals interacting between users and the suppliers of RT
products
Rehabilitation centres; schools for handicapped children; schools for professional
training; FSCMA (Swiss Federation of the Technical Aids Information Centres for
Disabled and Elderly people; PRO INFIRMIS and PRO SENECTUTE; Swiss Foundation
for electronic aids for disabled people; Swiss organisation for the Blind - Swiss
organisation for the Deaf.
Generally, professions engaged in service delivery are:
• rehabilitation medical doctors
• all kind of para-medical professions
• social assistants
• engineers
I.3.3 c) T rad e : producers, importers and retailers
All companies directly involved in the RT field are :
- FSCMA (Swiss Federation of the Technical Aids Information Centres for Disabled and
Elderly people). FSCMA is not selling equipments but provide information, user’s
specific test facilities and consulting, for instance, in Home adaptation.
- PRO INFIRMIS and PRO SENECTUTE, these Associations may help (consulting in
social and RT field as well as support for legal problems as well as financial) disabled
people and are grant-aided partly from the federal state (through the OFAS) and
partly by collecting money through gatherings.
- FST, Swiss Foundation for electronic Aids, providing technical electronic Aids more
specialised for physical handicaps. FST is divided into three departments: R&D,
PRODUCT (manufacturing selling, importing and exporting) and SERVICE DELIVERY.
At the end of 1993 : 20 employees. About 2000 disabled, in Switzerland, daily use
FST’s RT).
- C ooperative o f E lectronics for the D eaf (GHE/CES), s elf-help O rganisation p roducing,
importing a nd e xporting technical a ids for d eaf a nd h earing impaired p ersons, e .g.
text telephones, v isual a nd tactile a lerting s ystems, a nd a larm c locks. A t the e n d o f
1993: 1 0 e mployees. A pprox. 3 '000 text telephones in u se w ithin S witzerland.
- specific associations for physically handicap, blind and deaf people (run by disabled
mainly)
Note there is no association of retailer specialised in RT products and service delivery.
I.3.4 Products included in the delivery system
There is a non-exhaustive list (made and published by the OFAS) composed of the
recommended products and the description of the tasks and/or functions they may provide,
financially supported by the Federal Disability Insurance, but not a list of defined products
(by their names or type). This list is adjusted regularly. Note that nearly all RT products
tasks available today are mentioned in this list. To introduce new items in the list, the RT
company or user groups must demonstrate the cost effectiveness of the new aid, publish a
report and officially ask the OFAS if they accept to take care of the costs.
For RT electronic products, there is no official and specific testing and certification
organisation. Certification is de facto given when enough results have been obtained and/or
when a product approved by a testing laboratory somewhere outside Switzerland is
accepted by the concerned country.
If a technical aid is not available in Switzerland, it is rather easy for the user to obtain
imported products but under the condition a service facility is guaranteed.
I.3.5 Availability of information
Mainly, the permanent exhibition centre (EXMA which is relatively large, about 5’000 m2),
local exhibitions or temporary exhibitions a mong w hich w e c an m ention " Salon H andicap" in
Lausanne (took p lace 2 times u ntil e nd o f 1 993, s hould b e o rganised e very y ear in the
future) a nd " Pro L ife" in Z urich (took p lace o nly o nce u ntil e nd o f 1 993, s hould b e o rganised
every two y ears in the future). T hese b oth temporary e xhibitions a re e xisting for a r elatively
short time b ut they h ave b een m uch frequented b y R T p rofessionals a s w ell a s b y d isabled
persons a nd g ive a lot o f information o n R ehabilitation T ech n o logy o f e very k in d . There are
no official data bases besides local or company data bases. This information is used when
people know about the existence of such a service. This last point could be a problem in
Switzerland because the people not directly involved in rehabilitation are not familiar enough
upon the existence of such a permanent exhibition centre; we think mainly of general
hospitals and private doctors who should be informed.
The EXMA is controlled by the FSCMA. This private organism started about ten years ago
under the initiative of all main private charity organisations in the RT field. Today, the cost of
this organism is nearly totally covered by the OFAS. But FSCMA is still a private organism
run by a consortium of disabled specific organisms. Summarised activities of FSCMA are:
- permanent exhibitions
- consulting in RT field directly with the patient, independently of the RT manufacturer or
distributor
- managing the Swiss RT OFAS depot (with the exemption of RT electronics products made
by FST)
- technical maintenance, as a complement of the one made by RT companies
- FSCMA does not sell products or services. Their prestations are free of charge.
FST is specialised in High Tech RT products. It has, for information purpose, an electronic
database containing (1993) about 350 RT products, including a small description in French
and German as well as a digitised picture. This data base provides, for example, selected list
of items required by any individuals. Beside the list of products, FST runs a relatively large
specific documentation in the RT application field. Another database contains about 500
papers corresponding to 20 years of RT related activities. This documentation is not
exhaustive but contains at least many of the main papers written in Switzerland since RT
electronic aids dedicated to physically disabled were introduced and, since 1974, application
results presented by professionals and users with yearly congress organised, up to 1979,
by the Swiss company CARBA (one the first world-wide company in this field which, from
1972 to 1980, developed two generations of RT products with a distribution facility in
European countries as well as North America, Japan, Australia, New Zealand, Israel. From
1972 to 1980, CARBA sold equipment for cp children in 300 specialised schools which
concerned about 2000 CP children. For financial reasons, CARBA stopped its activities in
1980. As a consequence, the FST was then created).
I.3.6 Education of intermediaries
All the professionals (therapists, educators, teachers, social workers) involved do not
benefit within their study of a consequent and current formation on Rehabilitation
technology. They have the possibility to improve their knowledge later, under some kind of
permanent professional training. Training is available within:
- professional associations (organised in/or outside their own original universities or
schools)
- RT companies themselves
- individual training or information through organisations like FSCMA, Pro Infirmis
There are no general rules about the programme and duration of those trainings. For
example, FST organises a 4-days workshop about alternative and augmentative
communication aids, a 3-days one about special ergonomic computer keyboards emulation,
a 2 or 4-days workshop about environmental control systems. Note that training is available
in all RT areas.
Since 1993, there is also a ISAAC subsidiary organism, mainly in the German part of
Switzerland. ISAAC is one of the possibility professionals and disabled have to be informed
about aids and their applications.
I.3.7 User influence and empowerment
No official structure for testing RT products. The RT manufacturers/distributors usually
apply their own criteria. It usually means the users are strongly involved, they collaborate
with the manufacturers by transmitting their individual or collective feed backs, even on the
R&D level.
Main Users association concerned by RT field in Switzerland are:
- Swiss para-tetraplegic association and foundation
- Blind and depth associations
- CP’s parents associations
- CP’s foundation
- Mentally disabled parents association
- Rheumatism association
- Parkinson association
- Muscle dystrophy association
- ASKIO: “roof” association of many pathology specific disabled associations
- Multiple Sclerosis association
- Lateral sclerosis association
- ......
Most of these associations have direct contacts with the OFAS or political lobbies.
Users could strongly react if RT products do not correspond to their needs, just by not
requiring the use of them... They are always more structured in the RT field and this
situation lets strongly suppose that, in a couple of years, they will be much structured and
will certainly provide their own testing facilities, in collaboration with other countries.
I.4. The approach towards innovation
Any new RT product will be financially supported (see by whom for example in the previous
point 1.1.) when it is proven the product corresponds to the people’s need and when the
new product is cost effective. A good co-operation is ongoing between all partners involved;
they consider this fact as the most important parameter to be globally successful.
Research is made by different kind of partners. Co-ordination of R&D projects is not
officially organised but a “natural” way of co-ordination under structures depending upon
each project does exist. The “natural” co-ordination becomes for example automatically
when under the control of national or international R&D projects.
Official as well as private financial supports for R&D in this field are increasing, mainly b y
the Swiss National Research fund (only Swiss projects) at the Federal Office for Science and
Education (international projects)
I.5. Future developments in the system
As far as we know, not significant enough to be mentioned beside that international and
European co-operation will improve this situation and user’s organisation certainly will
organise themselves more in testing and/or approving RT products.
I.6. Impact on the rehabilitation technology market
The market is influenced by:
- demand coming out of recognised needs in this field by both rehabilitation professionals
and users association
- private users associations who publish, in their own publications, For example,
experiences made by their members
- offer proposed by the suppliers (encouraged for example by competition or new coming
technology which could increase new tasks facilities or consecutively to R&D national or
international projects
I.7. Strengths and weaknesses of the system
S trength s : financial support, information of the specialists in the rehab field. As a
consequence, always more knowledge is disseminated among the rehabilitation
professionals. It means that demand is always more accurately formulated. The financial
support which largely covers the total cost means that competition in the Swiss RT market in
becoming very strong, obliging that a lot of RT companies must increase the quality of their
products as well as their cost-effectiveness.
W eaknesse s : the offer is too large and not structured / not enough interest shown outside
the rehab field, mainly by general hospitals and private doctors; as a consequence, new
potential users do not know about the RT possibilities... One of the reason is certainly to
find in the relatively small percentage of RT potential users, compared with other patients, in
“standard” hospitals as well as by clients of private medical doctors not specialised in
rehabilitation
1.7. a) How it stimulates the market ?
The market is mainly stimulated because the insured knows the Federal Disability
Insurance will take care of the payment of the RT product/system he needs. The best
way of stimulating the market is to provide good financial support. The user should be
free from financial worries.
I.7. b) How the system improves the quality of the SD ?
The RT manufacturers/distributors try to improve the quality of the Service Delivery b y
organising workshops on the subject. The aim of these is to transmit the information in
the places where they feel the lack of concrete information (general hospitals or private
doctors). When it is possible, they organise this kind of workshops in lieu of the
hospitals, they also attend specific exhibitions (like Pro Life 93, IFAS 93, a.s.o.) o r
create their own exhibition.
PART II : The service delivery process
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The service delivery process is not significantly different from a disability area. Therefore, no
discrimination will be considered.
Preliminary remarks: We prefer using the name “DEMAND” instead of “NEED”; the need is usually
broadly recognised. RT products or services are the result of a demand, which is really lower than
the potential need could let it suppose.
After having looked at the HEART 7 steps proposal, we firstly would like to summarise the
procedure mainly used in Switzerland :
a) Identification of the demand (user directly, his/her family or rehab professionals of any kind).
b) Investigation in order to be able to consider the available range of RT products, via permanent
exhibitions or direct contacts with RT specialised companies.
c) Obtaining the possibility to test the products in order to check if the correlation between the
demand and the offer is suitable. Training is provided during this phase. The cost of a test is
mainly supported by the RT company (risk usually accepted, outside some exceptions, for
example when the RT product is especially designed or adapted to one specific user; in this
case, the RT company could receive financial support from the insurance).
d) 1. If the test is positive, an official demand is submitted to the social insurance. This demand is
made by the professionals around the user or a social service. The demand includes a
quotation made by the RT distributor. The time elapsed between the first contact with the user
and the day of payment is approximately the following:
- 1 to 2 month for testing the RT product;
- 3 months to get the answer from the insurance; RT company sends its invoice directly to
the concerned Federal Disability insurance
- 2 months to receive the payment
d) 2. If the test is negative, the case is closed until, for example, another RT product, better adapted
to the demand, is available. A new test is then started.
e) Technical maintenance is paid by the insurance, if the responsibility of the user is not engaged.
GENERAL
The RT product is attributed (by decision of the Federal Disability Insurance-OFAS/AI) to the user b y
name, but it does not belong to the insured. It becomes property of the Disability Insurance. The
user has the right to keep the attributed product as long as he needs it. If after a period of use, it
turns out that the insured no more needs the attributed RT product, he must return it to a so called
“RT products depot”. There, it will be revised and put at the disposal of another user under the
same conditions as above-mentioned. The difference lies in the fact that this time the RT device is
free of charge for the insurance (only manpower will be invoiced). For FST, active in the field of
environmental control systems, keyboard emulators, augmentative and alternative communication
devices, revised equipments attributed to new users represent about 50 % of the total equipment
installed in Switzerland in 1993 (it is to note FST manages, among other things, the Swiss “RT
products depot” for its traditional application fields, e.g. electronic aids like environmental controls,
communication aids and special keyboard emulators for computers).
After having summarised the “SWISS STEPS”, we come back to the 7 steps proposed by HEART.
II.1. The initiative
This is the first recognition of a need, either by the user, a professional or other person,
leading to any action to start the delivery process (for example application or referral). The
initiative can be taken by any of the above mentioned persons and there may be very
different procedures to be followed.
Everything is possible in this matter: the initiative may come from the user, his family, the
welfare workers around him and or the Rehab professionals. The initiative does not concern
the insurance as long as assessment and preliminary test have not been executed.
II.1.1. Are there (fixed) procedures for taking the initiative?
There are no fixed procedure for taking
the initiative.
II.1.2. If so, what are these procedures? -----------------
II.1.3. Who may start these procedures? No defined person may start the procedures.
Usually, its the professionals, if the disabled is in a specialised structure. If people
live at home, it could be themselves, their family or social assistants belonging to Pro
Infirmis.
II.1.4. Who are involved in these procedures (which professionals)? Mainly, the
professionals involved in those procedures are ergotherapists, special teachers,
doctors (rehabilitation specialists, neurologists, orthopaedists), social workers,
sometimes the user him/herself.
II.1.5. How accessible are these procedures (do people know where they have to go; is
sufficient information available)? No problems as long as peoples know to whom
they must first contact (very often Pro-Infirmis is the first contact)
II.1.6. If professionals are involved, who pays for their services ? Its depends on where
they come from and to whom they professionally belong to. But in any case, they
are paid. If they belong to a hospital, they will be paid by the hospital itself. The
hospital will then charge the rehab process to the concerned insurance. It also can
be paid by an independent occupational therapist, paid directly by the concerned
insurance.
II.1.7. What are the direct costs for the user (e.g., for technical aids and consultations)?
There are no direct costs to be charged to the user, unless what he needs is covered
by the decision (order) of the insurance. If not, private charity organisations may
give their contribution.
II.1.8. How long does this step take? The time elapsed between the first contact with the
user and the day of payment is approximately normally the following:
- 1 to 2 month for assessment testing and prescribing the RT product;
- 3 months to get the answer from the insurance; RT company sends its invoice
directly to the concerned Federal Disability insurance
- 2 months to receive the payment
II.2. Assessment
In this phase the need expressed by the initiator is identified and defined, and it is
determined whether technical solutions are appropriate. This assessment may be done b y
very different persons or organisations, using very different procedures.
This is to note that, in Switzerland, there are not specific approach depending of each RT
sector concerned. The professional concerned are not specific to the RT segment concern,
but by the pathology or the type of need to be satisfied.
II.2.1. Are there (fixed) procedures for the assessment?
No fixed procedure for assessment. Normally, a RT product choice is proposed to
the user. He will then try some of them. After that, he will be able to make his
choice.
II.2.2. If so, what are these procedures? -------------------
II.2.3. Who are involved in the assessment process (which professionals) ?
The professionals directly concerned by the area in which the assessment has been
done. (as an example, OT for wheelchair, Speechtherapists for communication adds
and ophthalmologists for visual impaired...)
II.2.4. How is the user involved in the process (for example possibilities to appeal against
decisions)?
In any case, the user is not obliged to accept or use a RT product he does not
want. Anyway, the concerned insured has the right to appeal against a negative
decision received from the insurance but he or the RT professional/family
responsible for him must clearly justify why he needs the RT product.
II.2.5. How is the assessment process financed?
No significant problems for the insured unless they are not retired. For elderly
people, the insurance changes and they automatically quit the Disability Insurance
to become member of the “State Pension Scheme Insurance for Elderly and
Surviving” (Assurance Vieillesse et Survivants). This is then a different status (see
second paragraph of the Preliminary remark of Part I, page 1)
II.2.6. What are the direct costs for the user?
Usually there are no direct costs for the users. The financing is covered by both
the RT company and the social insurance, it depends on which RT field the
assessment is made and on the kind of product. The professionals are paid in a
way which is specific to the structure they belong. Independents are paid directly
by the insurance. Professionals which are employees of a structure, receive their
salary directly from the structure and the structure will then charge the insurance.
II.2.7. What is the output of this phase and to whom is the output directed?
The output is: the assessment demonstrates that the RT device fully satisfies (or not)
the demand; it is then transmitted by the professional to the social insurance office
with the corresponding argumentation and quotation (no special form is required).
Note that selection, assessment and prescription are made by the same team.
II.2.8. Are decisions made in this phase already? Yes
II.2.9. If decisions are made, what is decided and by whom?
The decision for the payment of the RT product is taken by the local commission of
the disability insurance office, within a commission having a medical doctor, social
workers and member of the local administration.
II.2.10. If decisions are made, how is the user then involved?
The user will be involved only if the response of the insurance is negative. The user
has the right to appeal against the decision.
II.2.11. Are there written protocols for assessment used within the different procedures
and channels?
It is not the rules; but it is always more required or wanted.
II.2.12. How long does this step take?
Assessment depends on the problem submitted; it can take 2 days or 6 months...
II.3. Typology of the solution
On the basis of the assessment of the needs a specification of the functional requirements of
the technology is made.
II.3.1. Are there (fixed) procedures for this phase?
Not really; refer to FST’s description steps A to E.
II.3.2. Is so, what are these procedures? ----------------
II.3.3. Who are involved in this phase? (which professionals) ?
Idem point II.1.6.
II.3.4. How is the user involved in this phase?
The user is strongly involved (if the user is able to).
II.3.5. How is this phase financed?
Idem II.1.7.
II.3.6. What are the direct costs for the user?
Normally none.
II.3.7. What is the output of this phase and to whom is the output directed?
Selection of possible RT products to satisfy the expressed need; the information is
directed to the supplier(s).
II.3.8. Are decisions made in this phase already?
No, beside trying the product
II.3.9. If decisions are made, what is decided and by whom? -------------------
II.3.10. If decisions are made, how is the user then involved?
The user must approve the project.
II.3.11. How long does this step tale?
One day up to 6 months; depending on the problem.
II.4. Selection
In this phase a specific product is selected from the rehabilitation technology market or, if no
appropriate product is available, specifications for an adaptation may be made.
This phase of the process is strongly dependent on the information available on the market,
the knowledge of the people involved and, of course, the products available.
II.4.1. Are there (fixed) procedures for this phase? No fixed procedures.
II.4.2. If so, what are these procedures? -------------
For points II.4.3. to II.4.10. Idem points II.2.2 and II.2.3.
II.4.11. Are there recommended lists of aids that can be provided ?
There is no exhaustive list of products but just a list of tasks to be achieved by RT
products and, for each of them, a so-to-say “cost effectiveness habitude" (for
some items, like type writers for example, a maximum price is given). One reserve :
if the wanted RT product is providing more tasks than the one basically required
or if the product is more expensive than another, the user must pay, himself, the
cost difference between the product he wants and another cheaper available on
the market. In such cases, the equipment belongs also to the social insurance. In
extreme cases, there could be exceptions.
II.4.12 How long does this step take?
One day up to 6 months; depending on the problem.
II.5. Authorisation for financing
Approval for provision of the selected technical aid.
II.5.1. Who is approving?
The Federal social insurance office, normally at the county level (26 counties in
Switzerland)
II.5.2. When in the process is authorisation given?
After the assessment and test period.
II.5.3. What is the outcome of the approval (for example money or specific things)?
Money, the RT supplier sends its invoice directly to the concerned Disability
insurance office, after receipt of an order (positive attribution) from it.
II.5.4. What are the direct costs for the user?
Normally none (reserve described in II.1.11)
II.5.5. How long does this step take?
One day up to 6 months; depending on the problem.
II.6. Delivery
This phase includes all the activities concerning the actual delivery of the product to the
user.
II.6. a) Distribution: getting the product from the market (or the manufacturer) to the user
1. How are products distributed?
By RT companies.
2. How is distribution organised? Nothing relevant, depends on the area.
II.6. b) Installation (when necessary) and customisation: fitting the product to the individual
and his environment
1. Who is responsible and who does it?
The RT company
2. How is installation organised? (for example, by the financing or delivering
authority)
RT products are delivered and installed where the user is living.
3. Where does it take place?
Already mentioned.
4. How is it financed?
By the local social insurance.
5. What are the direct costs for the user? Nothing.
II.6. c) Instruction and training: informing and/or training the
user how to use the technology in relation to the
needs in the own environment
1. Who is responsible for instruction and training and who does it?
The RT company, sometimes in collaboration with professionals
2. How is it organised?
Training is organised at different levels. RT companies (at least organisation like FST
provide the professionals for workshops to train on RT products basically)
collaborators visit users where they are and provide for direct training.
3. Where does it take place?
In the place where the user is living.
4. How is it financed?
Sometimes included in the RT product prices, sometimes separately; in both cases,
training is paid by the insurance (this last point is really being available since 1992).
5. What are the direct costs for the user?
No direct costs for the user.
6. How long does it take?
One day up to 6 months; depending on the problem.
II.7. Management and follow-up
This phase includes all the activities after the product has been delivered.
II.7 a) Evaluation: evaluation of the effectiveness of the product in relation to the needs of the
user
1. Are there standard procedures for evaluation of the effectiveness?
No
2. If so, what are these procedures?--------------
3. to 6. Same partners as previous steps.
II.7. b) Maintenance
1. Who is responsible for maintenance and who does it?
The RT company or private non-profit organisation like FSCMA.
2. How is it organised?
Nothing relevant.
3. How is it financed?
By the insurance in case of technical problems due to a normal use of the RT
product.
4. What are direct costs for the user?
Usually none.
II.7. c) Repairs : this is to note that this is not depending upon the RT segment concerned, but
could be different regarding to which RT company is involved.
1. Who is responsible for repair and who does it?
The RT company or private non-profit organisation like FSCMA.
2. How is it organised?
Nothing relevant. Repair could be done within a few days or, for more complicated
items, it could take up to a month...In these cases, and when it is possible,
exchange is made.
3. How is it financed?
By the OFAS in case of technical problems due to a normal use of the RT product.
4. What are direct Costs for the user?
Usually none.
II.7. d) Insurance: especially concerning the responsibility if any damage is caused by defects or
in normal use.
1. Who owns the product?
The product is property of OFAS.
2. Who is responsible for insurance?
Their are no rules.
Sometimes, to be insured is obligatory (like for especially adapted cars), sometimes
not (environmental controls systems).
3. How is insurance financed?
By everyone earning a salary or any income. By automatic deduction on the salary
or income.
4. What are direct costs for the user?
Usually none, beside the above-mentioned rates.
II.7. e) Re-use of technical aids: when a product is not being used anymore, it might become
available for the users.
1. Is it organised and, if so, how?
All products not used anymore must go to specific depots to be controlled and
revised. If the product is highly technical oriented, the depot will be run by the
original corresponding company (FST runs the Swiss depot for electronic aids for
physically disabled people). For less specific product, the depot is under the
control of FSCMA.
2. Who is responsible and who does it?
Depending; sometimes the RT company, sometimes independent non profit
organisation like FSCMA (in that case, they will take care of standard RT products
only. High Tech RT products will be revised by the RT companies who distributed
them).
3. Does the user have a choice (can he decide to have a new or a used product)?
The user has no choice, in case what he wants is available in a depot.
II.7. f) Replacement criteria:
1. What are the criteria for replacement of the technical aid?
There are rules, depending on the aid. For example, an adapted car could be
replaced after 6 years of use. Generally, the RT product must be used as long as
possible. Only in case repair could not be realistically achieved, a new one could
be provided after examination.
Part III : Case Studies
________________
III.1 Computer peripherals for the blind
III.1 a) A man, 35 years of age, lives in a middle size city. He
works in an office with an average income. Due to
increasing blindness, he needs to improve his working
capabilities by using a computer with appropriate
peripherals .
First of all, this man has already more or less been informed about the available RT
products in this field, because he certainly is in contact with Pro Infirmis and the Swiss
organisation for the blind people. The assessment, the choice of the aid and a test will
be organised by an organisation (Computer Service for the handicap of the eyesight =
SERVICE D'INFORMATIQUE POUR LES HANDICAPES DE LA VUE = SRIHV; provides
consulting, products and adaptations specifically needed by blinds - non profit
organisation) specialised in the branch of computer adapted to the needs of the blind or
of persons suffering from trouble of the sight.
The training will be organised and given at the user’s work place. After the required test
period (about a month), if the test is successful, an official inquiry will be submitted to
the Disability Insurance; this will accept to finance the tested equipment under the
condition it is cost-effective and enables him keeping his job.
III.1 b) A girl, 10 years of age, lives in an urban area and
attends an integrated school (i.e., primarily for seeing
children). She has been blind from birth. As the academic
level of her work increases, she will need a computer both
at school to take notes and at home to do homework.
In this case, the girl is blind from birth and is studying in a special school where people
already have knowledge about RT possibilities. The Disability Insurance will provide the
girl for the necessary equipment, personally affected to the girl, at least at school,
maybe at home (the reason why she needs a second equipment at home must be very
well-argued...). Note that a student who needs RT products to be able to follow a
school programme will always have a financial support. The procedure to get the RT
required product is the same as the one described under point III1b.
III2. Aids for washing, bathing and showering
III.2 a) A woman, 42 years of age, lives in a rural area. She is a
housewife and her family has minimum income. She is
hospitalised with a hip fracture. She can now return home
but needs aids to help her to bathe, e.g., bath chair, brushes
with long handles
This situation is more complex. There are basically two kinds of RT products :
- the first category are the ones for which no fix installation is required (AQUALIFT)
- the second one, the RT products which must be definitively installed (SPECIAL
BATH, transformation of the bath-room)
For the first category of products, it is more or less easy to obtain the necessary
financing (both cases financed by the OFAS). For the second category, it is more
complicated : for example, a test before installing the RT product at home could only be
made in restricted situations like :
- visit of the EXMA exhibition
- asking for a FSCMA consultant who could come at home
- testing the equipment in a place where it is already in use (hospital, rehab. centres,
a.s.o.)
Financing the engaged cost in this case, is usually supported by the Disability
Insurance.
III.2. b) A man, 75 years of age, lives in a suburban area. He is
retired with average pension. He finds it increasingly
difficult to bathe.
There are nearly no financial possibilities outside private insurances, private funds or
charity foundations. Depending on the financial situation of the disabled, they could
pay totally, partially or not...
III.3. Manual wheelchairs
III.3. a) A woman, 25 years of age, lives in suburban area. She is a
housewife and mother, her family has average income. She
has a low spinal cord injury from an auto accident and will
be able to leave the hospital soon.
No problems: test ant assessment in the hospital - 100 % of the cost paid by the social
insurance.
III.3 b) A man, 90 years of age, lives in a nursing home. He
receives a small pension from former occupation. Due to
general weakness, he finds walking increasingly difficult.
Walking to the toilet and to the dining room of the home has
become a problem.
The wheelchair will be provided by the nursing home itself. In case the home would not
have such a wheelchair in stock, the nursing home may receive one from a depot
belonging to private organisations or social insurance for the elderly people.
III.4. Communication devices for speech impaired persons
III.4. a) A boy, 7 years of age, lives at home and goes to a special
school. His parents have below average income. He is
cognitively impaired from birth. He needs symbol boards to
communicate.
As soon as somebody needs a communication aid, he will receive one (a new one or a
communication aid coming from the “RT products depot”). Everything will be paid b y
the Disability insurance.
III.4. b) A man, 30 years of age, has been on disability insurance
for 3 years. He has multiple sclerosis which has affected
his voice. He is capable of handling computers with a
joystick or large keyboard and needs appropriate software
for communicating.
As soon as the patient will need a communication aid, he will receive one (a new one or
a one communication aid coming from the “RT products depot”). Everything will be
paid by the Disability insurance.
III.5. Telephone devices for the deaf
III5. a) A woman, 45 years of age, lives in an urban area. She has
been deaf from birth. She works in an office and has an
above average income. She has begun travelling in her
work as consultant to TIDE and needs a portable text
telephone .
S ince 1 983, the D isability insurance is p aying for a text telephone for e ach d e a f p erson
which c an r easonably p rove the r equirement for s uch a d evice. E ven a s econd o ne o r
a telefax c an b e p rovided b y the insurance s ince the 1 st January 1 993 .
B ut d epending o n the w riting s kills o f the w oman a nd h er text telephone p artners, text
telephone c alls w ill last 5 to 1 0 times longer than a s poken c ommunication o f the s ame
content. In c ontrast to G ermany a nd A ustria, there is n o c ompensation for those
higher telephone taxes in S witzerland a nd d eaf p eople w ill g enerally p ay 5 to 1 0 times
higher telephone c harges a s a c onsequence o f their h andicap .
In o rder to c ontact h earing p eople w ithout a text telephone, the w oman h as to u se a
telephone r elay c entre (PROCOM) w here trained o perators w ill translate s imultaneously
between text telephones a n d n ormal telephones. T here a re three s uch r elay c entres in
Switzerland for G erman, F rench a nd Italian w hich c harge 0 .33 C HF p er m inute o f c all.
This h igher than a verage c harge r esults in telephone c harges w hich a re 1 0 to 1 5 times
higher than for n ormal c a lls b eween h earing p eople .
III.5. b) A man, 68 years of age, lives in a rural area. He is retired
with an average pension. He has recently become deaf. He
is very active socially and wants a text telephone to
maintain communication with family and friends.
The Social Insurance for the Elderly and Surviving (AVS) will not pay one text telephone
(in case he became deaf before the age of retirement, then AVS will continue to pay).
Other private organisations may help him financially...
PART IV : Quantitative data
____________________
Data about service delivery of rehabilitation technology is sparse and is seldom consistent between
countries. An attempt will nonetheless be made to gather that d ata w hich is a vailabl e in the 16
countries studied.
Use data from the year 1990 whenever possible; otherwise specify the date in parentheses.
* total population 6’873’687
* % of disabled people 5.2%
14,38 % over 65 years old
* National income (ECU)199.7 milliard ECU
* The number of technical aids available for each ISO-class (level 1).
Concerning the number of technical aids available for each ISO-class (level 1), there are no
official statistics. One could suppose that all needed and recognised aids, independently on
where they come from are potentially available
* The number of aids provided for each ISO-class and the amount of money involved (in ECU
and as % of the national income)
Globally, the total amount spent on RT by the Federal Social Insurance Office (OFAS) amounts
to 95mECU in 1993 (67mECU for children and adults; 28 mECU for elderly people). For the
National Swiss Insurance in case of accidents (CNA), the corresponding amount for 1992 was
about 3.7mECU.
* Distribution of administrative and "real" technology related costs
Concerning the distribution of administrative and “real” technology related costs, no statistics,
as far as we know.
* The number of producers in your country, the number of national suppliers, and the number
of retailers/selling-points for technical aids.
For both producers and retailers no statistics at disposal, as far as we know.
------------------------------------------------------------------------------------------------------------------------
Concerning their traditional activities, FST answered this questionnaire according to its own
experience. For specific questions or questions not related to their traditional field, FST got in touch
with:
- L’Office Féféral des Assurance Sociales,(OFAS) BERN, Mr. H. Borner
- FSCMA, Oensingen, MR. Probst
The sources we used are the Acts and Documents concerning the Disability Insurance (AI) and the
State Pension Scheme for Elderly and Surviving (AVS), these papers are mentioned hereafter:
1. Federal Disability Insurance (from 1st Jan. 1994) Assurance-Invalidité (état au 1er janvier
1994)
Federal Acts Loi Fédérale
Administrative regulations Règlement
Federal Edict Ordonnance
2. Instructions concerning the attribution of Directives concernant la remise des moyens
aids by the Disability Insurance (01.01.1993) auxiliaires par l'assurance invalidité
(DMAI)(1.1.93)
3. Instructions concerning the attribution of Circulaires concernant la remise des moyens
aids by the State Pension Scheme for Elderly auxiliaires par l'assurance-vieilesse
(CMAV)(1.1.93)
and Surviving (01.01.1993)
4. State Pension Scheme for Elderly and Assurance vieillesse et survivants
Surviving (from 1st January 92) (état au 1er janvier 1992)
Federal Acts Loi fédérale
Federal Orders Arrêtés fédéraux
Administrative regulations Règlement
Federal Edict Ordonnance
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