Disability, Work and Inclusion in Croatia

3. Disability assessment in other OECD countries

Abstract

This chapter reviews disability assessment and determination systems in several OECD countries and beyond, highlighting how different institutional approaches have attempted – with varying degrees of success – to incorporate functioning into disability assessment. It identifies a shared international consensus that disability arises from the interaction between health conditions and environmental factors, and that assessments must therefore measure actual performance in daily life rather than infer disability from medical diagnoses alone. Across case studies, the chapter documents common shortcomings: misunderstanding of the ICF framework, untested functioning instruments, high discretion among assessors, decision making based on medical documents, and technically flawed scoring methods. The chapter concludes with lessons for Croatia, emphasising the need for psychometrically validated functioning tools, trained interviewers, standardised procedures, and clear rules for combining medical and functioning information.

In Brief

Disability assessment systems across the OECD area differ substantially, yet many countries continue to rely predominantly on medical information despite increased reference in their legislation to the International Classification of Functioning, Disability and Health (ICF) and the UN Convention on the Rights of People with Disabilities (CRPD). This chapter highlights challenges countries face in integrating functioning information into disability assessment and the importance of using scientifically validated and standardised tools to ensure fair, reliable and transparent assessment results.

Disability is best understood as an interaction between health conditions and the environment in which a person lives. International frameworks such as the ICF and CRPD emphasise that functioning or performance must be assessed directly, not inferred from diagnoses. Effective disability assessment requires clear conceptual distinctions between impairment, functioning and needs, and the use of validated tools applied consistently.

Most countries acknowledge functioning but continue to implement predominantly medical approaches. Attempts to bring functioning information into assessments often rely on instruments that mix unrelated concepts or use untested tools that lack psychometric validity. Assessors frequently rely on medical documentation and personal judgement rather than structured, evidence‑based methods, limiting the reliability of the assessment result.

Validated tools such as the World Health Organization’s Disability Assessment Schedule (WHODAS) provide a robust foundation for functioning assessment, but their use remains limited. Countries – e.g. including Moldova and the United States (in the US Veterans Affairs system) use WHODAS because of its strong scientific properties and international acceptance but changing assessment systems that have been in place for many decades proves to be difficult everywhere.

Case studies reveal recurring issues when countries develop their own functioning instruments. Across Armenia, Estonia, Latvia and Lithuania, tools often lack scientific grounding, combine ICF elements inconsistently, or rely on flawed scoring methods. Many instruments are overly complex or provide ambiguous guidance, enabling subjective interpretation and reducing decision consistency.

Functioning data are frequently undermined by inconsistent scoring and excessive assessor discretion. In many systems, assessors adjust functioning ratings according to expected limitations based on diagnoses, reinforcing a medical model. Functioning scores often have limited influence on final decisions, either because their weight is mathematically marginal or because medical interpretation overrides standardised performance measurement.

Countries that have advanced toward functioning‑based assessment approaches demonstrate what is required. Experiences from Chinese Taipei and Uzbekistan show that if a country wants to develop their own tool to assess functioning it requires sustained investment, multi‑year development, piloting, and extensive training to embed it into practice.

Key lessons for Croatia underscore the need for validated tools, harmonised methods and reduced discretion. A functioning‑based assessment system should use robust and psychometrically validated instruments and clear rules for combining medical and functioning evidence. Modernising assessment is essential to ensure fairness, objectivity and alignment with CRPD principles.

3.1. Bringing functioning into disability assessment

The World Health Organization’s notion of “functioning” – as the complete, lived experience of a health condition – provides the best basis for assessing disability for social benefits. Scientifically, functioning captures the current consensus about what disability is, namely the experience of actual limitations in performing activities in daily life that results from an interaction between impairments linked to diseases, injuries and other health problems, and the person’s actual environment – physical, interpersonal, attitudinal, and social. Functioning is also the basis of the human rights approach to disability found in the CRPD: the interaction between the person’s impairments and “attitudinal and environmental barriers that hinders their full and effective participation in society on an equal basis with others.” In short, functioning is both the scientifically, legally and ethically best basis for assessing disability for social benefits.

Similarly to Croatia and because of the political impact of the CRPD, many governments are urgently looking to reform their disability assessment and determination system. To this end, in recent years, many OECD countries have made concerted efforts to include functioning in their disability assessment with varying results. This chapter presents brief reviews of disability assessment and determination systems (DA&D) in several OECD and non-OECD countries, based on which it draws some lessons learnt considering such systems and their attempts to introduce functioning as an element of disability determination.

The chapter presents summary descriptions of disability assessment and determination in four EU countries (Latvia, Lithuania, Estonia and Belgium) and three non-EU countries (Moldova, Uzbekistan and the United States). The four EU countries were chosen to illustrate efforts to include functioning into existing disability assessment and determination systems, legally and institutionally, even if this is achieved only partially and with methodologies that have not been properly tested for their validity and reliability. In addition, for Latvia and Lithuania there are empirically based studies to evaluate their DA&D systems. Moldova was chosen as a country that uses a psychometrically robust instrument to assess and measure functioning, the World Health Organization Disability Assessment Schedule (WHODAS). Uzbekistan is presented as an example of a massive empirically based effort to include functioning into DA&D. Finally, the United States was included as it is a good example of WHODAS being used for the assessment of mental health conditions.

3.2. The consensus framing of DA&D

Modern thinking around disability and disability assessment has evolved a lot in recent years and the international scientific and political consensus can be summarised in the following propositions (Bickenbach et al., 2015[1]):

1. Disability is a complex phenomenon that is the outcome of interactions between the person’s state of health and the impact of all aspects of his or her physical, human-built, interpersonal, social and political environment (Cf. ICF (WHO, 2018[2]) and CRPD (United Nations, n.d.[3])).

2. The determination of disability is a matter of assessing the extent to which a person with health problems in their environment experiences limitations in activities and participation to the extent that raises the societal obligation to provide support.

3. The assessment of disability for disability determination is a summary measure of the overall level of a person’s performance of ordinary, everyday behaviours and activities, simple to complex, in his or her actual or usual environment, in light of the person’s state of health.

4. The assessment of disability should be the basis for determining the level of need for assistance, not the other way around. People need support because of their disability experience; they are not disabled because they need support. Disability determination and needs assessment are distinct administrative processes.

5. Disability cannot be inferred directly from a person’s health condition alone, as that ignores the impact of the person’s environment, and so it is incompatible with the ICF and the UN CRPD conception of disability.

6. Disability determination involves an assessment of the person’s state of health and an assessment of their summary level of functioning. Assessing functioning requires an assessment tool of some sort that has been tested psychometrically and so empirically proven to be valid and reliable.

7. How the medical assessment and the functioning assessment are combined is ultimately a political decision for each country, although for scientific legitimacy and transparency it should be based on an empirically derived algorithm.

8. The legitimacy of the disability assessment process depends on it being impartial, fair and based on objective evidence. Assessments should be valid (no “false positives” or “false negatives”) and reliable (two assessors following the same rules and criteria, should come to the same assessment of the same person – “inter-rater reliability”), and decisions should be publicly known (transparency) and their application in particular cases independently evaluated (standardised).

9. As every person with a disability has the basic human right to work if they wish (CRPD (United Nations, n.d.[3])), the focus of work capacity determination should be on disability-related obstacles to work, and the supports that can be provided to overcome these. Labour market engagement of a person with disability, as well as measures needed to ensure that she or he remains employed, are a matter that requires co‑ordinated actions and involvement of the person, her or his employer, employment office, social insurance and social services and social assistance office. Labour market conditions such as jobs availability play an important role as well. Ideally, actions would start, and a plan made, prior to the person being referred to disability assessment and would be followed through after the disability assessment decision has been made.

10. The WHO Disability Assessment Schedule has been developed, tested and consistently recommended by the WHO as a generic, performance‑based disability assessment tool. WHODAS has been extensively used in many applications and has been thoroughly psychometrically tested and shown to be both valid and reliable. Data collected by WHODAS can be statistically analysed to produce a measurement scale with interval scale measurement properties.

3.3. Observations from case examples

Many countries claim that they have introduced an assessment of “functionality” into their systems of disability assessment and determination. Formally, this is correct, as reference both to the term and the ICF is made in legislation. Yet, in practice, assessment and determination remain essentially medical, as explained by the following:

A profound misinformation and misunderstanding about ICF. Countries will either merely state, in their legislation or procedures, that they are basing their assessment on ICF, but do not actually use it, or try to use ICF when they develop their own instruments to assess functioning (see Box 3.1 and Box 3.2 for two examples of countries’ attempts to develop their own instruments based on ICF). However, a closer look shows that their instruments are not aligned with ICF: the instruments are often a mixture of symptoms (“How frequent are your seizures”), body structures and body functions impairments, and simple activities – but rarely participation – questions. Some instruments divide “functionality” into “mental” and “physical”, which the ICF does not do. And, for the most part, these instruments do not show an understanding of the difference between collecting information from the capacity perspective (i.e. ignoring the impact of the person’s environment) or from the performance perspective (i.e. taking both the health condition and the environment into account). The performance aspect is critical in any disability assessment for benefits and supports a person requires in their actual lives. To capture that information, the instrument must, as WHODAS does, make it clear that the respondent has considered all aspects of the actual daily life. From the performance perspective, activities and participation are the critical domains. ICF body functions and body structures, and the impairments that result, are more relevant to the person’s underlying health condition, and only indirectly to their level of disability. Yet, countries in their own instruments, perhaps in an attempt to be “comprehensive” mix all these categories up, which makes their instruments unable to produce a meaningful summary score of disability.

Most of the countries’ own instruments have never been properly tested, if at all. Any instrument to assess functioning must be tested for psychometric properties. In other words, the instrument must be statistically shown to capture the construct of disability as characterised by the ICF and the CRPD, validly and reliably. Moreover, for most purposes, the instrument must also be able to produce a measurement scale that has interval scale measurement properties, so that the scores from the instrument are mathematically meaningful, i.e. the higher the score, the more severe the disability. Some instruments claim to have been “field” tested, but results are not available publicly, and, in any case, field testing is not the same as a rigorous psychometric testing. The psychometric testing of a self-assessment instrument in Latvia and of an Activities and Abilities Questionnaire in Lithuania has shown that neither of the two instruments passes essential psychometric tests emphasising the point that no instrument to assess functioning should be deployed without proper psychometric testing.

Lack of uniformity and standardisation in implementing the instrument: The same instrument often features different ways of rating answers to questions (e.g. Estonia), the instructions are not clear whether the answers should consider the impact of the environment or not, and in some cases the interviewer is instructed not to consider the impact of the environment but to note down the use of assistive devices. This lack of a standardised approach reflects a confusion about what and how it is assessed.

Assessors’ discretion is huge. Assessors are given large discretion of how to rate answers, although this fact is not overtly expressed, and indeed is hidden beyond procedures. The assessors are often simply asked to “take into account” the state of health of the person, his or her answers, the use of assistive aids, and so on, without providing any structured formula for how these disparate items are to be combined for a decision. This is especially the case in systems where information on functioning comes by means of a self-assessment instrument and where the final ratings are made by assessors. It is often not clear what the assessors are supposed to do with the information from self-assessment or what role it plays. Often, assessors are instructed directly to rate functioning according to what is consistent or expected based on the state of health alone. In this way, the assessment of functioning becomes an assessment where functioning is inferred directly from the state of health, which is invalid as shown by numerous scientific studies. To avoid this overwhelming reliance on discretion – overt or hidden – it is vital that the functioning assessment instrument be implemented in a face‑to-face interview by a trained professional to record the data, and that this procedure is separate from the medical assessment. Indeed, the interviewer should have no knowledge of the person’s health condition, to minimise bias.

DA&D systems almost exclusively employ medical doctors. Medical doctors are the appropriate assessors of states of health. Although that is obvious, it is also clear that medical doctors are not the most suitable to assess functioning. Most medical doctors, other than physical and rehabilitation medicine physicians, have little experience or training in functioning, understood from the perspective of performance of activities and participation in the actual environment. In most instances, it is preferable that functioning be assessed by social workers, psychologists, rehabilitation or occupational therapists, professionals who are more aware of the actual lives and performance of the people whose disability they are assessing. Again, it is preferable that assessors are not aware of the full medical record of the individual to avoid any bias.

Use of a variety of additional instruments: Many systems use an array of additional tools to assess functioning (e.g. Functional Independence Measure – FIM, Barthel Index, etc.). The added value of these tools to assess functioning is questionable because there is little evidence showing a correlation between the items used in these instruments and the ICF domains, or validation of a matching between the rating scales of these instruments and the ICF 0‑4 scale. This is not to say that these instruments should not be used for the purpose for which they were developed: FIM to measure progress in rehabilitation treatment, Barthel to assess the need for assistance in patients with mobility problems due to stroke and so on.

Technically dubious methods to derive the functioning score. Functioning questionnaires tend to adopt the ICF rating scale of no problem (0), mild problem (1), moderate problem (2), severe problem (3) and extreme problem (4). It is important to note that this is a qualitative, not a quantitative rating scale, and the numbers are not intended to represent anything other than the order of the ranking – i.e. technically it is an ordinal scale. Therefore, these numbers cannot be added up or averaged – “cannot do” is not mathematically twice “moderate”, nor is “mild” 1/3 of “severe”. Despite this, countries often sum up the rates from the answers to their questionnaires and then divide the raw scores into groups of “functional” difficulty; in some countries, coefficients from the scores are derived and applied to the medical percentages of impairments; other countries calculate averages of rates by domains (even giving higher weights to some domains), while other countries calculate averages across domains and then divide them into severity levels. But none of these techniques are mathematically meaningful; the rating scores are not quantitative. The only way to generate a valid cardinal score is to model the raw scores by Item Response Theory or Rasch Modelling, which transforms the raw score into a score on a scale of 0‑100 points. This is a well-known method in the scientific literature and can be easily applied.

Increasingly, the need for assistance is used as a criterion to assess functioning. Conceptually, this is not ideal, because it is disability, i.e. the interaction between a person with a health condition and her or his environment that created problems in functioning (i.e. disability in the ICF) and these problems generate and determine needs, not the other way around. The need is a signal to alter the person’s environment to optimise their functioning.

Methodology to conduct medical assessment varies. Sometimes countries use Baremic tables that link diseases with the percentage of disability, sometimes they use tables that describe levels of impairment associated with a particular disease, and then either link these levels to severity of disability or just equate them to disabilities. In some cases, e.g. Estonia and Italy, there are no standardised guidelines at all, and the medical assessment is largely a matter of the assessors’ discretion.

Discretionary decision making to determine disability prevails. As said above, in many instances the final decisions about disability and severity of disability are made with no clear method or algorithm. Typically, there is a general statement that the decision will be based on medical information, limitations in functioning, need for assistance or some other “relevant” factor, but there is no guideline or rule about how this is to be accomplished. Even in the case where there is a formalised algorithm (e.g. Moldova), the impact of the functioning assessment is minimal. Given how impactful information about the person’s state of health is throughout the entire process, the medical approach to disability determination seems to be the most important in all countries.

To sum up, there are many reasons, some historical, some political, explaining why the medical approach dominates DA&D. The deeply ingrained perception that disability is entirely a medical issue, coupled with the fact that medical professionals are generally trusted by the population, are salient factors.

Box 3.1. A cautionary tale for other countries: Armenia’s instrument to assess functioning

Armenia’s recent attempts to reform its disability assessment and determination system by including the assessment of “functionality”, especially for the assessment of working activity, demonstrates a lesson about what countries changing their disability assessment and determination systems should avoid.

From 2017 to 2023, Armenia engaged consultants to develop a regime of, and build capacity for, a “functional disability assessment” rooted in the ICF. Armenia’s process of assessment is similar to many other countries: applications are initiated on a dedicated e‑disability platform, personal information and a self-assessment forms are completed and medical records (diagnostic data and relevant clinical test results), which are reviewed and verified by specialists, a multi-professional (physicians, psychologists, Occupational Therapists) assessment committee is formed and a formal assessment is performed and disability is determined. The essential final step, however, was key: integrating a valid, ICF-based functioning assessment into the assessment and determination decision.

The Government of Armenia passed legislation that finalised this last, crucial, component of disability assessment and determination. The legislation – “Standards of Personal Functioning Assessment for the Purpose of Working Activity” – aimed to approve criteria and tools for assessing “functionality”. In fact, the Act merely claims that ICF is the basis for the criteria and tools and repeats the ICF 0‑4 ordinal scale (No problem, Mild problem, Moderate problem, Severe problem, Total or Complete problem). The legislation goes on to say that this will be described in another document, the “Methodological Guidelines for the Assessment of Personal Functionality”, to be approved by the Minister of Labor and Social Affairs.

The ministry engaged health experts to develop a tool based on the advice of the consultants. After extraordinary efforts, many months of work, and considerable expense the result was a detailed, functioning assessment tool developed by the country: The Methodological Guidelines consists of 80 ICF domains (for which there is neither justification nor validation) each with the five ICF ratings of 0‑4. Each of these ratings, for each domain, is transformed into a nominal description (e.g. “mild walking problem” might be nominally described as “being able to walk without assistance at least 20 meters over smooth ground, but not more than 30 meters without assistance”). In addition, different nominal scales were created, for each of the 80 ICF domains, to be provided for four age‑groups (3‑5, 6‑14, 15‑18, 18 plus) and for different, representative, health conditions. The content of each of these several hundred nominal descriptions is aligned with one of 15 international standard instruments (e.g. Functional Independence Measure – FIM, the Berg Balance Test). The result is an extraordinarily complex and extensive, nearly 300 pages long, clinical tool.

However, the Methodological Guidelines are completely inappropriate for assessment of functioning in the ICF sense. No justification is provided for the selected 80 ICF items. There is no validation for linking any of the nominal descriptions to the ICF rating scale for different domains, let alone different age‑groups. There is no evidence supporting the correlation between the international, standardised instruments and the ICF domains, nor any validation of how the rating scale of these instruments matches the ICF 0‑4 scale. Despite all these issues, the Methodological Guidelines might have some clinical use to profile patients in terms of their health conditions. However, the application of the Guidelines would take hours or days to do completely, whilst most disability assessments in other countries take at most 20‑30 minutes.

In the end, what the Guidelines cannot do, is assess functioning. There is no way to align the nominal scales of different ICF domains (e.g. why would a “mild” walking problem be the same severity of disability as “mild” vision problem?); moreover, the ICF rating system, although for convenience uses the numbers 0‑4, is ordinal because it is qualitative: mild, moderate, severe. Because it is ordinal, the numbers 0‑4 cannot be added up or summed (i.e. it is meaningless to say that “mild plus moderate equals …”) In short, the Guidelines have no measurement properties, no summary score can be created, and so no final assessment of severity of functioning problem can be determined.

Because of the considerable investment in time, resources and expertise, Armenia will likely be forced to use the Methodological Guidelines going forward. However, the Guidelines are, scientifically, inappropriate for this purpose. As this example also shows, countries should be careful in their attempts to develop suitable functioning assessment instruments that have the essential psychometric properties of validity and reliability – tools of the established scientific status of WHODAS. Unless done properly, countries should avoid developing their own functioning assessment tools, to avoid Armenia’s pitfall.

Source: Conclusions by Jerome Bickenbach based on an extended visit to Armenia and various unpublished national documents.

Box 3.2. A unique example: Chinese Taipei’s disability assessment system in a nutshell

Chinese Taipei is an example, nearly unique in the world, in which there was a slow, multi-decade development of disability assessment and determination processes and instrumentation that was both ICF-based and conducted entirely by means of rigorous scientific research. Since 1980, the Government of Chinese Taipei has enacted legislation to govern disability determination for disability benefits, which was, until 2007 entirely based on medical criteria. In 2007, the People with Disabilities Rights Protection Act was adopted, launching a concerted effort on the part of the Ministry of Health and Welfare to develop disability assessment consistent with the ICF and the recently passed (2006) CRPD.

The Act mandated that, by July 2012, the assessment of individual eligibility for disability benefits must be based on the ICF framework. To achieve this, starting in 2007, a taskforce was created to design ICF-based disability assessment tools and to compare the differences of disability grades between the old system and the use of these tools (Chiu et al., 2013[4]). The taskforce consisted of physicians, dentists, nurses, physical therapists, occupational therapists, social workers, psychologists, special education teachers, and vocational assessment workers. To supplement the medical diagnostic part of assessment, the taskforce, supported by several medical associations, began to develop and test an assessment tool for body functions (BF – ICF b codes) and structures (BS – ICF s codes). A core set of body functions and structures were developed through consensus conferences and for each category of BF and BS, standard medical examination tools were identified to provide baselines for a rating scale, which in turn was adjusted in light of the taskforce physicians’ clinical experiences, consensus meetings and empirical data analyses of pilot studies. This was a multi-year process, culminating in 2011.

Over this same period, another group of researchers were developing what was to become the core of Chinese Taipei’s Disability Determination System (DDS), namely its approach to the assessment of functioning in terms of ICF categories of activities and participation in light of environmental factors. Between 2007 and 2012, the Taskforce met a total of 75 times to come to an agreement on the ICF (and at the time, the then current ICF-CY version) items that would be in the instruments. A first attempt was made using the ICF checklist (see WHO ICF web page), but that was superseded by the development of the Functioning Scale of the Disability Evaluation System (FUNDES) in two versions, one for adults and another for children. It was decided that, to secure the scientific foundations for FUNDES, that the 36‑item version of WHODAS (although known to have strong psychometric properties) should first be extensively tested in Chinese Taipei for disability assessment. After WHODAS was translated for testing purposes, WHODAS was piloted on roughly 15 000 applicants for disability benefits as well as an additional pilot for older adults specifically to determine WHODAS sensitivity to dementia‑associated disabilities (Chiu et al., 2014[5]; Huang et al., 2016[6]).

Based on the analysis of the WHODAS pilot results, the taskforce concluded that WHODAS should be the foundation of FUNDES-Adult, as well as that five additional items from the participation dimension should be added for use in Chinese Taipei. In the end, the FUNDES tools, after another five years of testing in the field, were finalised and it was time to compare the difference that using the Body Function and Structure and the FUNDES tools made, as compared to the old system of medical assessment. Data from 7 098 persons over the age of 18 were evaluated using both systems, with the result that there was only 49.7% agreement of disability grades between the old and new systems (Teng et al., 2013[7]). An independent analysis of the data models of ICF and the new DDS approach confirmed that, after nearly a decade of development and testing, their new approach was far preferable (Chi et al., 2013[8]).

By 2021, the Government of Chinese Taipei had completed the process of reforming their disability assessment and determination procedures which involved fundamental alterations to the structures of the governing institutions to streamline the process. An amendment to 2007 Act was required as well. The government addressed the remaining areas of resistance to the new system, and the DDS approach has been continuously monitored to ensure reliability and public acceptability (Chi et al., 2020[9]; Liao et al., 2022[10]).

The Chinese Taipei example is unique, and the result is a complex, multi-layer procedure which may have to be modified and simplified in subsequent years. The primary lesson to be learned is two‑fold: First, extensive reforms of a complex, bureaucratic and politically sensitive administrative procedure such as disability assessment and evaluation takes time; it is not a reform that can be hurried, nor are there easy fixes or shortcuts. Secondly, every step in the nearly two decades of the Chinese Taipei reform was supported by state‑of-the‑art scientific research to validate not only the assessment instrument itself, but also the process and the public reaction. These are important lessons for other countries.

3.4. European Union countries

3.4.1. Latvia

The current system

In January 2015 Latvia made significant changes to its disability and work capacity assessment and determination system. Conceptually, it moved from approaching disability as a purely medical issue to a biopsychosocial understanding of disability as characterised by the ICF and CRPD. Below a summary description of Latvia’s DA&D is presented as it was in 2019-2022 (Posarac, Celmina and Bickenbach, 2020[11]).

Legal framework

The DA&D in Latvia is regulated by The Disability Law (Government of Latvia, 2010[12]; Government of Latvia, 2014[13]) which defines disability as a long-term or non-transitory limitation of functioning that impacts a person’s mental or physical abilities, work capacity, self-care, and social inclusion. In Latvia, to access any government funded benefit, a person must be certified to have a disability or loss of ability to work by the State Medical Commission for the Assessment of Health Condition and Working Ability (SMC). There is only one certification of disability applicable to all benefits and the number of eligible benefits depends on the severity of the disability.

Disability due to the loss of ability to work is determined for working age adults (from 18 years of age until mandatory retirement age of 65). Depending on the restriction of functioning, its degree and the percentage loss of ability to work, the Law defines: (a) disability Group I, if the loss of work capacity is 80‑100% – very severe disability, (b) disability Group II, if the incapacity for work is 60‑79% – severe disability, and (c) for disability Group III, if the loss of work capacity is 25‑59% – moderate disability.

For children, disability is determined without classification into groups. For persons in retirement age, depending on the restriction of functioning and its degree, three groups are determined: disability Group I – very severe disability; disability Group II – severe disability; and disability Group III – moderate disability.

The Law also recognises “predictable disability”, defined as a restriction in a person’s functioning due to a disease or injury that, if not addressed with appropriate medical and rehabilitation services, could lead to a recognised disability. Predictable disability is only rarely assigned, and it is not described further here.

The Law stipulates that an assessment and determination of disability/work capacity is conducted if a person has a physical or mental health disorder due to which they have been continuously treated for at least six months before the date of the application to SMC. It may be conducted earlier, if the health disorders are severe and with an unfavourable prognosis or the functioning limitations have become permanent. A person can request a reassessment at any time if their state of health has significantly deteriorated and the resulting functioning impairment is considered permanent.

DA&D administrative process and criteria

DA&D in Latvia is a formally regulated administrative process, which is briefly described below. The process is partially automated.

1. Initiating the process: medical referral to the SMC and self-assessment

A Referral to the SMC (Form u‑088) is filled out by a general practitioner or the patient’s treating doctor. It should contain detailed and substantiated information about the applicant’s state of health with the ICD codes and an accurate and complete description of the state of body functions and body structures with appropriate qualifiers as in the ICF. The form can be filled out and signed manually or electronically. In most cases, the referral form is filled out in a paper format. The medical report and supporting medical documents are issued to the patient in paper form, although the Latvian health system is undergoing rapid digitalisation, so medical information is often available digitally.

An applicant (from 18 years) also must fill out a “Self-assessment of limitations in functioning. The questionnaire contains 21 questions from four domains of functioning: understanding and communication (e.g., “Concentrating on some work for 10 minutes”), mobility, self-care and home life and work. The responses options are: “no difficulty” (0); “slight difficulty” (1); “moderate difficulty” (2), “great difficulty” (3) and “very great difficulty” (4). The person is instructed to consider whether the performance of the relevant activity requires major effort or causes discomfort or pain, the speed of performing the activity, and whether the way the activity is performed has changed. The self-assessment contains questions about activities that may cause difficulties for a person due to his or her physical and mental health.

2. Application, registration and assignment of an assessor

Once a person has been issued a medical referral, has filled out a self-assessment questionnaire, and obtained other required documents, they must formally apply to SMC. The SMC Client Service registers the application; a SMC officer reviews it and assigns an assessor to the case. The assessment and determination should be completed within one month. The SMC has the right to decide on a longer review of the application (up to four months) if there are objective reasons for this (for example, the required documentation is missing or incomplete). The person must be informed of such a decision.

3. Case assessment and report

The assessment is conducted without a face‑to face meeting with a patient. It relies entirely on information provided in the Medical Report and accompanying medical documents. It assumes that the doctor has provided an accurate and complete account of the applicant’s state of health. In practice, medical reports often consist of just two or three handwritten sentences, which can be hard to decipher. If the available information is insufficient or contradictory it is possible to carry out the assessment in-person. An in-person review is also usually carried out when a decision is appealed.

Criteria for DA&D are found in two tables: I. Health disorders assessment table (Table 3.1) and II. Functioning ability evaluation table (Table 3.2).

Table 3.1. Latvia – health disorders assessment table for adults

	Severity of health disorders
	Mild	Moderate	Severe	Very severe
Description of symptoms	Symptoms are controlled with treatment or there are periodically mild symptoms despite treatment	Despite continuous treatment, mild symptoms or intermittent moderate symptoms persist	Despite continuous treatment, moderate symptoms or periodic severe symptoms persist	Despite continuous treatment, severe symptoms or periodic very severe symptoms persist
Physical examination data	Physical state is found normal or periodically mild	Despite continuous treatment, the physical state is found mild or intermittent	Despite continuous treatment, the physical state is found is moderate or intermittent	Despite continuous treatment, the physical state found severe or periodically very severe
Laboratory instrumental examination data	No changes or periodic changes	Despite continuous treatment, slight changes or periodic moderate changes remain	Despite continuous treatment, moderate changes or periodic severe changes remain	Despite continuous treatment, severe changes or very severe changes over time persist

Source: Posarac, Celmina and Bickenbach (2020[11]), Latvia – Disability Policy and Disability Assessment System, http://documents.worldbank.org/curated/en/099310306132234252.

The Functioning Ability Evaluation Table contains a small selection of items from the ICF body Functions classification and the Activities and Participation classification domains (5 out of 9) with a total of 21 items (out of more than thousand items from the ICF) (WHO, 2018[2]).

• Body functions: cardiovascular, hematopoietic, immune and respiratory system functions, nervous-musculoskeletal and motion-related functions, specific mental functions, sensory functions and pain.

• Body structures: none

• Activities and Participation domains: learning and knowledge use, communication, mobility, self-care, interaction and relationships with other people.

Table 3.2. Latvia – an excerpt from the “Functioning ability evaluation table”

ICF body functions	Notes
1. Specific mental functions 1.1. b140. Attention (persistence, change, breakdown) 1.2. b144. Memory (short-term, long-term) 1.3. b164. Advanced cognitive functions (abstraction, organisation and planning, comprehension, reasoning, problem solving)	Attention – evaluates the concentration of attention in the required period, the change of attention, as well as its division into two or more stimuli at the same time. Memory – Evaluates short-term and long-term memory. Abstraction – a logical process in which the thought deviates from the insignificant, random features of an object or phenomenon and separates, fixes their general and essential features. Abstraction – creation of abstract concepts; generalisation. Organisation – to unite (what) in a certain whole, in a system (usually to achieve a goal). Sort, create (what) planned, co‑ordinated. Planning – an ability or process that ensures gradual, sequential, purposeful and effective behaviour. Self-awareness – awareness and understanding of oneself and one’s behaviour. Judgment – the ability to form a judgment. Problem solving – the ability to identify and analyse conflicting information and find a solution
Degree of restriction: 0 – no restriction; 1 – mild restriction; 2 – moderate restriction; 3 – severe restriction; 4 – very severe restriction.

Source: Posarac, Celmina and Bickenbach (2020[11]), Latvia – Disability Policy and Disability Assessment System, http://documents.worldbank.org/curated/en/099310306132234252.

A case designated SMC expert assessor reviews the documents and prepares an assessment report. The case assessment report should provide a comprehensive description of the assessment with conclusions and recommendations regarding the degree of disability or work incapacity. The completed and signed report is forwarded electronically to a SMC official for a decision.

Expert assessors are instructed when assessing functioning domains and determining a degree of functioning to consider how it manifests itself, in terms of the performance of the activity, pace, energy consumed, as well as the result achieved.

1. Case assessment report review and decision making

An official of the SMC reviews the assessment report and, in the case of working age adults, decides on the applicant’s disability severity group or loss of ability to work in percentage, as well as the cause and a period of disability. The official also issues an opinion on care needs in cases of Group I disability.

The decision may be:

• No disability: If no functioning restrictions are found or carrying out an activity is easy – it does not cause significant problems to function – disability is not determined. The individual could still be identified as having a loss of general ability to work for up to 24%, but this is not regarded as a disability for the purpose of the assessment.

• Group III disability: Functioning restrictions are moderate if functioning is substantially limited, but not so much that the restrictions would be severe (daily activities can be done independently, but at a substantially slower pace or with more effort, or worse quality compared to the normally accepted standard for the corresponding age group). Group III disability is determined when the loss of ability to work is assessed at 25‑59%.

• Group II disability: Functioning restrictions are severe if functioning is substantially limited, restriction is higher than moderate but is not very severe (most of daily activities can be done independently, but at a substantially slower pace or with more effort, or worse quality compared to the normally accepted standard for the corresponding age group, with episodic need for help or supervision. Group II disability is determined, where the loss of ability to work is 60‑79%.

• Group I disability: Functioning restrictions are very severe if functioning is very limited or practically impossible, creating a need for permanent or frequent help or supervision in daily activities. Group I disability is determined, where the loss of ability to work is 80‑100%.

Disability and work capacity in cases of occupational health: In cases of an accident at work or occupational disease, a disability group and/or loss of work ability is determined based on a list of diseases and assigned percentages of work incapacity to each one of them. In deciding on the final percentage of work incapacity, other information plays a role: whether a person has other significant health problems, the impact of the impairment on everyday life activities, as well as the person’s age, education, work experience, labour status, competitiveness in the labour market and job forecasts.

Disability and loss of ability to work are determined for one, two or five years or for life. Concurrently with or after determining disability or loss of ability to work the SMC official makes a judgment about the need for (i) a specially adjusted car and an allowance for the compensation of transport expenses; (ii) special care; and (iii) service of companion (only for children).

2. The issuance of disability decision, appeals and grievance redress

The decision on disability is transferred to SMC Client Service that notifies the applicant about the decision, opinions and recommendations. If the applicant is not satisfied with the decision, they may contest it with the SMC Head whose decision can be appealed to the Administrative District Court. A person with disability or loss of ability to work has the right to request a repeat assessment at any time, if their state of health and functioning has deteriorated significantly or has stabilised and no improvements are expected.

Observations concerning the current DA&D system in Latvia

• The self-assessment form was developed locally and has not been tested for validity and reliability. The self-assessment questionnaire is not scored. It is not clear whether the results have any impact on the final decision. The WHODAS pilot study that was conducted in Latvia (Fellinghauer et al., 2022[14]) tested the psychometric properties of the functioning categories in the self-assessment form with the objective to investigate whether these ICF categories could be validly and reliably summarised in one summary score as in the case of WHODAS. The essential psychometric tests indicated that the self-assessment form could not be used to create a summary score of functioning.

• DA&D is entirely paper-based and there is no face‑to-face interaction with the applicant. This prevents the applicant from more completely describing the level of functioning loss they are experiencing, in the context of their actual day-to-day life.

• Overall, the system is gradually moving towards a broader, functioning-based assessment approach consistent with the principles of the ICF. At the same time, medical information remains an important component of the assessment process, and the disability or work capacity decision is still mainly made based on the Medical Report form, even if it is increasingly aimed to be used to understand the functional consequences of health conditions rather than to determine disability solely on the basis of medical diagnosis.

• In practice, therefore disability in the DA&D system in Latvia is exclusively a medical issue. Disability is, in effect, inferred from information about the person’s state of health. The impact of the person’s environment, which may improve or worsen performance, is ignored. While the disability status groups in the current system are described in terms of functioning limitations, in practice the only source of information used is medical.

The reform plans

Following the analysis of the disability system and policies in Latvia and empirically based proposals on including functioning into DA&D from the WHODAS pilot, as well as extensive internal technical discussions and consultations with stakeholders, a methodological proposal/report that envisages a systematic inclusion of functioning into DA&D and the use of WHODAS was prepared by the Ministry of Welfare. A proposal on disability reform, introducing an increasingly broad integration of functioning information into disability assessment, is planned to be submitted to the government in 2026. At the same time, it should be taken into account that the reform requires budget expenditures, therefore real policy changes could be introduced from 2030 (taking into account an agreement that line ministries would not submit any new policy initiatives that require state budget co-financing until 2030 except for defence spending and few crucial initiatives).

3.4.2. Lithuania

Below a summary description of Lithuania’s disability and work capacity assessment and determination system is presented as it was in 2019 to late 2022 when the WHODAS was pilot tested. Then the changes to the definition of disability and the DA&D system introduced since December 2022 are described (Posarac and Bickenbach, 2020[15]). Lithuania is an interesting case of how country-specific disability approaches, policies and systems evolve over time.

The DA&D system until late 2022

The key legislation regulating DA&D system in Lithuania is the Law of the Republic of Lithuania on Social Integration of Persons with Disabilities (Goverment of Lithuania, 1991[16]). The government body responsible for the DA&D was the Disability and Work Capacity Assessment Office (DWCAO) under the Ministry of Social Security and Labor (MSSL). Criteria and procedures for DA&D were determined by ministers of Social Security and Labor and Health (Government of Lithuania, 2025[17]), and further elaborated in orders issued by the director of the DWCAO.

The Law recognised three groups of persons with disabilities: (i) children and adults not covered by mandatory social insurance assessed to have a disability level (mild, moderate or severe); (ii) working age adults (16‑65) covered by mandatory social security assessed to have a reduced work capacity (55% or less); (iii) adults who have reached retirement age for whom a level of special needs is determined. Each was assessed and determined by DWCAO, but procedures for the assessment differed in medical criteria and the application of criteria to assess functioning.

Assessing and determining disability and the level of special needs included determining: (i) a Base Disability Level – a medical criterion, expressed as a score based on the individual’s state of health and related body functions impairments. The scoring was based on points assigned to each listed medical condition or impairment, and (ii) an Autonomy Coefficient – a measure of a person’s functioning in everyday life (mobility, nutrition, personal hygiene, social relationships) and their cognition, perception and behavioural abilities. Upon receiving the needed information, the DWCAO designated officer would review the documents and propose the decision on the level of special needs to the management. The decision making algorithm was not available publicly.

The work capacity assessment and determination (Government of Lithuania, 2025[17]; Goverment of Lithuania, 1991[16]) was conducted by DWCAO after all needed medical and vocational rehabilitation and special aid measures have been undertaken, and the health condition has become permanent and immutable. The standardised administrative process included a referral to DWCAO by the person’s treating physician with a binding list of medical examinations (e.g. Barthel Index, Functional Independence Measure, Pain Rating Scale, IQ, Mini mental test, psychological personality profile, and so on); an application and case registration; the appointment of assessors (at least two); a face to face interview to collect information on functioning; a review of documents, work capacity percentage determination and issuance of decision.

Criteria: Work capacity was evaluated in 5 percentage points (p.p.) intervals, ranging from 0 to 100% (where 0‑25% = total incapacity for work; 30‑55% = partial capacity for work; and 60‑100% = a person is able to work). The assessment consisted of two sets of criteria: (i) medical criteria to determine basic work capacity that is then adjusted by a coefficient created from (ii) the person’s activity and ability to participate as assessed by the Questionnaire of the Individual’s Activity and Ability to Participate (A&AP). Medical criteria was a traditional Bareme table where each medical condition/impairment was assigned a (disability or loss of work capacity) percentage value. The A&AP questionnaire to assess functioning comprised 26 questions grouped under five domain headings: mobility, application of knowledge, interaction, independence and daily activities. Each question was scored using a nominal scale – i.e. each item was described in terms of what the individual can or cannot do relevant to the nature of the item, and whether and at what level assistance by others is needed. These descriptions were scored 0, 1, 2, 3 or 4. At the end of each domain, a series of dichotomous (yes/no) questions were asked about the need for assistance relevant to the domain.

The scores were summed and the sums transformed into coefficients defined by experts ranging from 0.7 to 1.2. These coefficients were automatically applied to the medical percentage for the final work capacity percentage.

An analysis of the final disability percentages showed that the effect of the functioning coefficient was minimal on work capacity, so that, the assessment was essentially based on medical criteria alone (Posarac and Bickenbach, 2020[15]). In 2018, the activity and participation score changed the medical score meaningfully only in 1.74% of cases.

The assessment of work capacity associated with occupational diseases and work injuries was solely based on medical criteria.

Changes since late 2022 (the current system)

In December 2022, the Law of the Republic of Lithuania on Social Integration of Persons with Disabilities was changed significantly (Goverment of Lithuania, 1991[16]). Subsequently, legislation regulating the DA&D process were revised as well, including new terminology, updated tools, and unified medical criteria for all adults. The amendments to the Law introduced a concept of disability that is based on a “person’s participation level”, understood to reflect how their health condition affects their everyday functioning and their need for assistance. This assessment of the level of participation is a mandatory step for determining disability status and accessing the need for social support. The process is co‑ordinated by the Agency for the Protection of the Rights of Persons with Disabilities (referred to as Agency hereinafter, previously DWCAO) under the MSSL. Decisions are made by the head of a territorial division, and the Agency operates in all counties.

Below the key changes are briefly described and the DA&D system is presented as it currently functions.

The Law changed some key definitions. For example:

• Disability – a long-term functional impairment of a person’s body (congenital and/or acquired characteristics) which, due to environmental factors, prevents a person from participating fully and effectively in society on an equal basis with other persons.

• Person (adult) with disabilities is a person for whom the level of disability or the level of participation of 55% or less has been established.

• Level of participation – a comprehensive assessment and determination of a person’s opportunities and abilities to participate fully and effectively in society, considering the person’s disability and environmental factors.

• Individual assistance needs – the needs of a person with a disability arising from his or her disability and/or environmental factors that prevent him or her from being independent in performing daily activities.

• Level of disability (for minors) – a comprehensive assessment and determination of a person’s ability to develop fully and participate effectively in society.

The Law now differentiates between (i) disability (for minors not covered by social security) and (ii) the level of participation for adults, as well as minors covered by social insurance. The notions of work capacity (for working age adults) and the level of special needs (for persons over retirement age) were thus consolidated into the notion of the level of participation.

Determining disability (children) (Government of Lithuania, 2025[17]): Broadly, the notions and the method for determination remain as they were until December 2022. The level of disability (mild, medium and severe) is determined for children up to 18 years of age, except for those covered by the state social insurance.

Determining the level of participation (adults and minors covered by social security): The Law stipulates that the level of participation is determined based on an assessment of the persons health state and the influence of environmental factors on their independence, the possibilities for effective participation in the life of society and the disorders of the functions of the person’s body after all possible medical measures have been used and considering the extent of the need for individual assistance. Participation is measured as a percentage and is determined at intervals of 5 p.p. The method to determine the level of participation combines a basic participation and the individual’s need for assistance scores.

Determining a Basic Participation (Medical Part)

The Agency evaluates an individual’s basic participation level using a scoring system based on medical conditions organised by ICD chapters, applying specific coefficients reflecting the level of impairment (no‑0, mild‑1, moderate‑2, severe‑3 and very severe‑4 (Table 3.3)). The premise is that the basic level of participation depends solely on health condition.

Table 3.3. An excerpt from the criteria to assess an individual’s basic participation level

No.	Criteria and their description	Score (impairment level)
8.	Extrapyramidal system and movement disorders (Parkinson’s disease is assessed according to the modified Hoehn and Yahr stage scale: Stage 0 – there are no symptoms of the disease Stage 1 – the symptoms of the disease are characteristic of one side of the body Stage 1.5 – unilateral and axial (axial) symptoms Stage 2 – symptoms of the disease characteristic of both sides of the body, balance is not disturbed Stage 2.5 – mild bilateral disease, the displaced person persists Stage 3 – mild or moderate degree of mutual disease, postural instability, person physically independent Stage 4 – severe disability, the person can still walk or stand on his own Stage 5 – the person does not get out of bed or the wheelchair without assistance):
8.1.	symptoms of the disease are characteristic of one side of the body, unilateral and axial (axial) symptoms, there are no imbalances, hyperkinesis is blurred, bradykinesia; Stage 1‑1.5 of Parkinson’s disease	0
8.2.	symptoms of the disease are characteristic of both sides of the body, balance is not disturbed, the pushed person persists, experiences difficulties in performing some household chores, takes three to four times longer; Stage 2‑3 of Parkinson’s disease	1
8.3.	a person can still walk or stand on his own, can do most of the household chores, albeit very slowly, with great effort, makes mistakes, is unable to perform some tasks; Stage 4 of Parkinson’s disease	3
8.4.	symmetrical impairment of functions on both sides of the body, characterised by postural instability, pronounced hyperkinesis that interferes with daily activities; the person does not stand, does not walk, does not get out of bed or in a wheelchair; Stage 5 of Parkinson’s disease	4

Source: Order of the ministers of SSL and health on the Description of the Criteria and Procedures for Determining the Level of Participation. Consolidated version from 5 February 2025, Annex 1. https://www.e-tar.lt/portal/lt/legalAct/TAR.D1F619C285A0/asr.

In the scoring, a primary diagnosis and up to 5 co-morbidities are scored separately. The primary health condition is automatically scored at 39 points. It is then multiplied by the impairment level (1, 2, 3 or 4) from the medical (i.e. “basic participation” criteria): assigned points for the level of impairment (1, 2, 3 or 4) × 39. Thus, the maximum number of points for primary diagnosis is 39 x 4 = 156. There is no publicly available explanation of the underlying technical rationale for the scoring method, i.e. it is not clear why 39 points were chosen, and so on. Up to five significant comorbid conditions may be considered. Each is assigned a score from 1 to 4, based on severity. These scores are multiplied by corresponding coefficients as follows: Score 4 → Coefficient 4; Score 3 → Coefficient 3; Score 2 → Coefficient 2; and Score 1 → Coefficient 1. In theory, the maximum score from comorbidities can be 80 (5 co-morbidities, each 4x4 points). The total medical or basic participation score is a sum of all points. Hypothetically, the highest score can be 236 (156+80) and the lowest 39 (only a primary health condition; no comorbidities).

Determining the need for individual assistance

This is assessed in a face‑to-face interview conducted by a community social worker. The standardised questionnaire consists of two parts: detailed personal information – Part 1), and a mix of 49 items from the ICF body functions and activities and participation sections grouped in five groups: cognition, movement (mobility), self-care, communication and daily activities and participation (engagement). Each item is scored from 0‑4 based on the assessed need for help: 0 points – no need for assistance; 1 point – minor need for assistance: 2 points – moderate need for assistance; 3 points – significant need for assistance; and 4 points – constant need for assistance. In total, the score pertaining to the level of need can range from 0 to 196 points.

The questionnaire also contains a section on environmental factors. There are 17 items grouped as: products and technology; help and provisions by others, including attitudes and prejudice; services and support provided by professionals; and civic protection. The environmental factors are not scored but checked if relevant with description. The instructions say that the assessment of environmental factors is carried out by considering the physical and/or social environment in which the person lives and spends time. Environmental factors are assessed considering the specific situation of the person being assessed. No instruction is given how to make this assessment, and no point system is provided. If an environmental factor is selected as relevant, that suggests that it has an impact on the person’s need for assistance in different areas of life.

Calculating Total Participation Score

This score is calculated by adding: the basic participation score and the need for individual assistance score, which is then turned into a total participation level expressed in 5 p.p. levels from 0% (the total score/points of 401‑432) to 55% (the total score/points of 55‑80). This algorithm was developed by the MSSL experts.

The criteria also provide for variations in rules to determine the level of participation. For example, there is a list of health conditions, including cerebral palsy, multiple sclerosis, spinal cord injury, and severe mental retardation, as well as a person who is in palliative care where disability/level of participation is determined as severe automatically, without medical or needs assessments. Furthermore, the criteria for determining disability in cases of occupational diseases and work accidents have remained unchanged (based on medical criteria using a Bareme table).

Key observations

In Lithuania, until late 2022 DA&D was formally based on both medical and functioning criteria. The medical criteria followed a standard Bareme approach in which diseases and impairments were assigned a percentage of disability. The functioning criteria were based on the Activities and Ability to Participate, which, as data analysis indicated, did not adequately capture the construct of functioning and was unreliable (Posarac, Fellinghauer and Bickenbach, 2021[18]). Analysis showed that, in practice, the functioning score had almost no impact on the final decision on disability. The assessment of disability associated with occupational diseases and work injuries was also solely based on medical criteria. Therefore, the assessment and determination of disability was based on medical criteria alone. The results of the WHODAS pilot in 2021 strongly suggested that the inclusion of WHODAS into DA&D would greatly improve its scientific validity and reliability. However, the changes introduced in December 2022 and onwards took a different path.

In the new system, disability is determined based on “participation”, which is itself assessed by a combination of a medically based “basic participation level” and a needs assessment. The “basic participation level” is assumed to be solely determined by a medical problem – assessed by assigning a rate to a specific medical conditions and impairments. The rates are ordinal: 0, 1, 2, 3 and 4 (effectively representing the qualitative levels of “no problem”, “mild/moderate”, “severe” and “very severe”). For reasons not explained, 39 points are used as the base score, and these ordinal numbers 0, 1, 2, 3 and 4 are then used as multipliers of this number. This scoring methodology contains a mathematical error: The numerical values 0, 1, 2, 3 and 4 do not depict cardinal but only ordinal values, e.g. 2 is not half of 4, because “mild/moderate” is not mathematically half of “very severe”. This confusion makes it appear as if a mathematically precise score is being created when, in fact, the score is mathematically meaningless. The only way to transform this scoring algorithm into something mathematically meaningful is to transform the scores – 0, 1, 2, 3 and 4 – into true cardinal numbers, based on a single linear metric. To create such a scale, so that the scores are mathematically meaningful would take extensive empirical evidence to demonstrate that, e.g. Level 2 symptoms are half as disabling as Level 4 symptoms of body functions impairments. This research has not been done, and this step in the assessment is therefore highly problematic.

More fundamentally, the assumption in this approach is that the person’s state of health – their diseases, injuries and impairments – equals their “basic participation level”. This is entirely in contradiction to the characterisation of participation in the ICF, and indeed the definition of “disability” in Lithuania’s own legislation. Disability in the ICF and CRPD and as adopted in Lithuania is determined both by medical and environmental factors. This definition of “basic participation level” ignores the environment.

The basis for calculating the total participation percentage – combining the basic participation level (level of impairment) with need for assistance score (which itself is the sum of 49 individual scores) – has the same difficulty. These numbers cannot be added together; they do not share the same metric. But, even if all these issues were resolved the resulting total participation score would not conceptually be disability (aside from the fact that participation cannot be measured in p.p.), as defined by the ICF, the CRPD and Lithuania’s own legislation. Disability is the outcome of the interaction between the health state of a person and the physical, attitudinal, and social environment in which he or she acts and live out life. Disability is what people do, their performance in a range of activates and participation and shaped by their environment.

In conclusion, the new DA&D system in Lithuania does not assess disability; it assesses separately the level of body functions impairments and the needs for assistance.

3.4.3. Estonia

The 2016 reform

Estonia reformed its disability/ work ability determination system on 1 July 2016. Key legislation includes the Work Ability Allowance Act (Government of Estonia, 2014[19]), which regulates the assessment and determination of work ability, and the Social Benefits for Disabled Persons Act (SBDP Act) (Government of Estonia, 1999[20]), which regulates the assessment and determination of disability and benefits for people with disability. They are operationalised by ministerial and administrative decrees and orders.1

The 2016 reform, inter alia:

• Separated disability and work ability determination between the Social Insurance Board (SIB) and the Unemployment Insurance Fund (UIF). The SIB determines disability of children up to 16, persons of retirement age and persons of working age. The UIF determines the work ability of persons of working age.

• Disability pension from mandatory contributory social insurance was abolished and a disability allowance, funded from the state budget, as an instrument of labour market policy was introduced.

• Procedure, methods and criteria for disability and work ability were changed by introducing the assessment of “physical and mental abilities”.

The SBDP Act describes disability as “a loss of or an abnormality in an anatomical, physiological, or mental structure or function of a person, which in conjunction with different relational and environmental restrictions, prevents participation in social life on an equal basis with others.” The Act establishes three degrees of disability: moderate, severe and profound. They are described differently for children up to 16 years of age and persons of retirement age and working age adults. Accordingly, the assessment and determination methods differ as well. In the case of children and persons of retirement age, the Act stipulates that the degrees of disability are to be established “proceeding from the need for personal assistance, guidance or supervision”. For working age persons (from 16 to retirement age), the Act posits that the profound, severe or moderate degree of disability is established proceeding from restrictions in participation in daily activities and social life: Profound disability – daily activity or participation in social life is totally restricted; Severe disability – daily activity or participation in social life is restricted; and Moderate disability – the person has difficulties in daily activity or participation in social life.

The Work Ability Allowance Act differentiates between three levels of work ability, which are established based on the “state of health of a person and restrictions in activity and participation arising from the state of health, and the prognosis and estimated duration of such restrictions.” They are full work ability, partial work ability and no work ability.2

The description of the levels of work ability and degrees of severity of disability of working age persons match, because they are assessed with the same instruments and methods: no work ability closely matches profound disability, while severe and moderate disability match a partial work ability notion.

Disability and work ability assessment and determination

The SBDP Act defines general rules for determination of the degree of severity of disability.

DA&D of children and elderly persons is carried out by the SIB. It is a precondition for them to receive some benefits, both in cash (e.g. a disabled child allowance and an allowance for disabled person of pensionable age) and in kind (e.g. services). Some benefits can be accessed without a disability severity certificate. Eligibility to social services is subject to additional needs assessment. Legally, the determination of a degree of disability for children and for persons of retirement age is linked to the care needs. According to the SIB, for persons of retirement age, the degree of disability is determined in light of long-term permanent limitations that cannot be controlled with treatment and who, despite technical aids, require additional help or support services to cope with basic daily activities (Estonian Social Insurance Board, 2023[21]). An increased need for more frequent doctor appointments and medication than usual is not considered a basis for determining the severity of disability. Without a determination, however, a person can apply to the local government to receive income support and technical aids at discounted prices. A person unable to cope with daily activities can contact a local government social worker who will assess the need for help and offer available support services, such as a personal assistant or social transport. If these are inadequate, the person can apply to SIB to determine the severity of disability.

The SIB assessment is conducted by medical doctors (assessors) and is based on data from the application form, the health information system (e‑health), rehabilitation plan (if one exists) and other relevant sources. The assessment is paper-based, and the medical expert assessor, except in rare cases, does not meet the applicant face‑to-face. When conducting the assessment, the expert compares the information provided by the applicant in the self-assessment form against what in the expert’s opinion could be expected (inferred) from the medical records. If the expected level of care needs based on the medical information differs from the ones reported by the person, the medical expert assessor’s assessment prevails.

There appears to be no formal method or guidance for assessing and determining disability of a child under the age of 16 and of a person of pension age (ANED, 2019[22]). The SIB determines the severity of the disability based on an opinion of the medical assessor and, if necessary, other relevant data.

An assessment and determination of work ability and disability of working age adults (Estonian Social Insurance Board, 2023[23]) is needed for a person to receive a work ability allowance, disability allowance, and other benefits. The methodology for the assessment of work ability was prepared by the Estonian Society of Occupational Health Physicians in 2013, commissioned by the Ministry of Social Affairs. It states that it was developed in accordance with international recommendations, relying on the ICF (Ministry of Social Affairs, 2020[24]). Persons with partial work ability must comply with at least one from a long list of labour market activity requirements to receive the work ability allowance. Some benefits and services, including access to assistive aid at discounted prices (40%) are available without a work ability/disability determination.

The disability severity degree of working-age persons is determined if a person of working age has “a long-term or permanent limitation in participation and performance, which, despite treatment and the use of technical aids, prevent her/him from coping with the tasks of everyday life, they can request the determination of the severity of the disability” (Estonian Social Insurance Board, 2023[23]). The purpose is to support work and access to work of persons with reduced work ability through work-place adjustments, rehabilitation and occupational interventions, provision of assistive aids, and work ability allowance (Ministry of Social Affairs, 2020[24]).

A person of working age can apply to (i) UIF for determination of work ability only; (ii) SIB for determination of disability only; (iii) either SIB or UIF for both work ability and disability determination. In either case, UIF determines the work ability first and then sends the decision and all relevant documents to SIB, based on which SIB determines the degree of disability severity. Before applying, it is important that a general practitioner or a medical specialist has made an entry describing the health condition and the resulting limitations in the e‑health information system (digital health records) within the last six months.

Work ability does not need to be determined in the following cases: (1) ailments associated with a malignant tumour or hospice care when onco-specific treatment is not available; (2) dialysis treatment; (3) artificial ventilation or constant oxygen therapy for respiratory insufficiency; (4) dementia; (5) moderate, severe or profound intellectual disability; and (6) permanently bedridden (requiring 24‑hour personal assistance). The underlying assumption is that they have no work ability.

Steps to determine work ability and disability of working age adults in Estonia are summarised below.

Application: Filling out the application form is one of the most important steps in the process. The application form (Estonian Unemployment Insurance Fund, n.d.[25]) is a comprehensive 60‑page document, with inter alia detailed personal data, consent to access the e‑health system, contact details of health professions visited, use of personal assistance, rehabilitation and social services, the “Physical and mental abilities” self-assessment, and work information.

The “Physical and mental abilities” is a self-assessment questionnaire that comprises seven domains, where a domain is understood as a “practical and meaningful aggregate of mutually related physiological functions, anatomical structures, activities, tasks, and scopes of activity” (Ministry of Social Affairs, 2020[24]). The domains are: Physical abilities (movement, manual activity, transmission and receipt of information, and staying conscious and self-care), and Mental abilities (learning and implementation of activities, adapting to change and perception of danger and communication). The last section (8) asks questions about “Effects of addictive substances and side effects of drugs”. Each domain consists of several “key activities”. There are 18 such activities. Under each key activity, there is at least one question (there are a total of 27 questions) where the applicants are asked to rate their ability to do something or how big a problem is. In many cases, questions are phrased as Are you capable of… or Can you…, and the multiple‑choice answers are yes; with little difficulty; with moderate difficulty; with great difficulty; almost impossible; not; and my ability to… is variable. The applicants are not instructed whether when answering questions they should consider their environment. However, there are questions on which they are instructed not to consider the assistive aid, or someone’s help they have. There are also questions where the applicants are asked to separately provide information about the assistive aid or personal help they use.

Medical expert evaluation: Applications are evaluated by SIB/UIF’s medical doctors (expert assessor) (Government of Estonia, 2016[26]). The assessment is based on medical information from the e‑health and the applicant’s self-assessment of “physical and mental abilities”. Additional information can be requested from physician(s) listed in the application. Assessors are obliged to consider the applicant’s use of assistive devices and her or his compliance with the prescribed treatment. The assessors use case information to rate “physical and mental abilities”. They choose qualifiers from a pre‑determined table for each of the questions in the “Physical and mental abilities” questionnaire (Government of Estonia, 2016[26]). The pre‑determined correspondence table does not apply qualifiers uniformly (e.g. in some cases “I cannot do” is rated 4, in others 3). By way of assessment methodology, the medical expert is advised to consider the applicant’s self-assessment of “physical and mental abilities”, but only if, based on the medical data, the reported restrictions correspond to expected difficulties based on the applicant’s health state. The assessor changes the rating according to his opinion.3

According to the Regulation 18/2016, the numerical values of qualifiers denote the following:  0 – no restriction detected; 1 – slight restriction: a restriction that does not particularly interfere with a person’s daily life or occurs less than 25% of the time; 2 – moderate restriction: a restriction that often hinders a person’s daily life or occurs 25‑50% of the time; the activity is clearly more difficult to carry out than for a person without long-term health damage; 3 – severe restriction: a restriction that significantly interferes with a person’s daily life, occurs very often or continuously; performing the activity is almost impossible, but still feasible to some extent; and 4 – total restriction: a restriction that constantly interferes with and hinders everyday life; It is not possible to perform the activity. After rating each question, a degree of severity of key activities is determined as equal to the highest of the point values of the questions in each key activity.

The results of the assessment are recorded in detailed assessment report that includes information about the state of health, its impact on “physical and mental abilities”, rating of all key activities (including the original rating from self-assessment and the expert’s rating with explanation), and so on.

Determining the degree of severity of disability (SIB): SIB determines a degree of disability of a person of working age considering data from the application, the medical expert’s assessment report and other relevant data. To determine a disability severity degree, the Regulation 18/2016 stipulates that an arithmetic mean of restriction from the numerical values of the level of restrictions in key activities in each area is calculated. SIB can adjust (with justification) the arithmetic mean of restriction and the numerical values of the severity of the restriction occurring in the performance of key activities in the domain by 0.5 units. While the rules to calculate the arithmetic mean of restriction are complex, in their simplest application the severity of disability is determined as follows: (i) Moderate disability – arithmetic mean of restriction = 2.0‑2.75 points; (ii) Severe disability – arithmetic mean of restriction = 2.76‑3.49; and (iii) Profound disability – arithmetic mean of restriction = 3.5‑4.0.

The SIB decision on the degree of severity of disability includes: the degree of severity; areas with at least average degree of disability; duration of decision; the time to apply for a reassessment; and based on what disability was/ was not determined. The decision is a base on which disability allowance is awarded (its amount depends on the type of impairment: mobility, visual, etc., and the severity of disability).

Assessing and determining a work ability (UIF) is conducted in cases of a long-term and permanent health condition, i.e. the state of health that is not expected to change significantly within two years. The methodology, which is described in detail in the Ministry of Social Affair’s Methodology is very similar to the SIB determination of disability. It specifies that a reduction in work ability may result from: a medical condition that precludes the ability to work; restrictions in activity and participation in one activity; and a limitation of activity and participation in a combination of several actives and domains.

A UIF medical assessor rates items in the Physical and Mental abilities questionnaire (the same one as for the SIB disability – see above). Like in the case of SIB disability, the rating should be based on medical information from e‑health, a self-assessment of physical and mental abilities, the applicant’s stated will to engage in activities, dependence on alcohol or drugs and the use of assistive devices. The qualifiers to rate items are 0 (no problem), 1 (mild problem), 2 (moderate problem), 3 (severe problem) and 4 (very severe, cannot do, total problem) and they are pre‑determined in the above‑mentioned Correspondence Table. If the applicant has indicated that the condition is variable, or if the self-assessment rate is not what is expected from the state of health, the expert doctor chooses the rate based on the state of health.

According to the Methodology, the value of a key activity score determines “the severity of limitation”, while the sum of the scores determines “the degree of capacity to function”. When the sums are scored, qualifiers 0 and 1 are excluded, i.e. only scores 2, 3 and 4 are considered. The key activity score, if it contains more than 1 question, is determined by the question with the higher score. The domain score is determined by the key activity with the highest score in the same domain. Work ability is determined based on the key activity and domain scores, as follows. (i) The applicant has no ability to work if: s/he is diagnosed with disabling health condition; any of the key activities score = 4 across the domains and the combined effect of the domain capacity limitations is that the person is unable to work; special case (there is no severe (3) or total limitation (4) in the applicant’s ability to work, but the assessor, based on the state of health, decides that the applicant has no work ability). (ii) The applicant has partial work capacity, if key activities scores across different domains are <4 and the combination of different domains indicates a partial capacity to work; the claimant is unable to perform any of the key activities independently without assistance, but the assessor has determined that the wok ability is partial; special case (discretionary decision by the assessor). (iii) The applicant can work if the score for any key activity across different domains is ≤ 3.

However, the above is more of a guide than a set of rules, because assessors are given a wide discretion to determine the level of work ability. In exercising their discretion, the Methodology states that they should consider the combined effect of the person’s impairments in different areas, the extent, course, severity and frequency of the impairment or disease, the person’s disease awareness, the person’s willingness to accept treatment and the impact of the impairments on daily activities.

The medical expert prepares a detailed assessment report and sends it to UIF that decides on the work ability. The concluding opinion in the assessment report must also include recommendations on suitable and unsuitable working conditions and, where appropriate, recommendations on the use of assistive devices and work capacity support.

Observations

While in Estonia disability and work ability can be determined separately, they often are determined jointly, using the same application form and information. Work ability precedes disability determination, and the latter is based on the former. It is not clear how and to what extent work ability determination impacts decisions on disability. Conceptually, this is problematic, since it is disability that impacts work ability. Moreover, according to the CRPD, each person with disability has the right to and can work, irrespective of the severity of disability.

The state of health is assessed based on the data from the e‑health system. How exactly it is assessed, how the body functions impacted by the health condition and the level of impairment are identified is not publicly available. Hence, based on the publicly available information, the assessment appears to be at the discretion of the medical assessor.

The self-assessment questionnaire of “Physical and Mental Abilities” is problematic for many reasons: (i) The questionnaire contains a collection of questions, some of which pertain to symptoms of diseases, some are linked to body functions and some to activities (there are no participation questions). Very few can be truly matched to the ICF (which does not distinguish between “physical” and “mental” abilities). (ii) The scoring modalities are not uniform, moving from ratings of severity to frequency or duration; nor is the uniform links between the qualitative ratings (“mild”, “moderate”, “severe”) and the numbers assigned to them. (iii) More significantly, the ratings are treated as quantitative, when they are at best ordinal. The digits 0‑4 correspond to the ordinal scale qualifiers (from no to complete problem) and they are not numbers that can be added or averaged – i.e. “cannot do” is not mathematically twice 2 (“moderate”) or 1/3 higher than “severe” 3 – although that is what the regulation requires. Finally, (iv) there is no evidence that the questionnaire has been validated or has measurement properties of validity and reliability.

Applicants are often unclear about whether to consider their environment when responding and sometimes are told not to. Environment is mostly narrowed down to assistive aid. But functioning (which the self-assessment purports to describe) is a measure of difficulty in performing activities in daily life and participating in social life in the person’s own environment in the light of his or her state of health.

As in the assessment of the state of health, the assessors are given a large discretion in interpreting the self-assessment results. As noted, the assessors are asked to determine if answers are consistent with the health state, and if not, to rate the answers based on the expected impact of the health condition. In certain situations, abilities are inferred by assessors based on the health state only.

In all, the system to determine disability and work ability in Estonia is only remotely linked to the ICF, it is primarily based on medical information and is notable for relying on discretionary judgements of medical assessors. Because of this, the system has substantial transparency, validity and reliability concerns.

3.4.4. Belgium

In Belgium, there is no formal disability certification. Disability is determined in terms of capacity to earn income in the context of eligibility for federal benefits and the needs for assistance in the context of eligibility for regional benefits. It is a complex system that reflects Belgium’s institutional and territorial structure. It is also highly regulated.

Federal level benefits

Persons with health problems that adversely impact their capacity to work and earn income are eligible to receive: (i) Invalidity pension that provides a long-term income replacement for salaried workers and self-employed individuals unable to work due to illness or non-work-related accident. It is administered by the National Institute for Sickness and Invalidity Insurance (NIDI). The applicant must experience a reduction in earning capacity due to a health condition (verified by medical exams and specialists), that has lasted or is expected to last more than one year. The person must meet a minimum invalidity insurance contribution history and must have a determined incapacity degree assessed as a percentage of lost earning capacity (33%, 50%, 66%, or full incapacity). The assessment is conducted by the Federal Agency for Occupational Risks (FEDRIS) doctors. The process is initiated through the health insurance fund (Mutuelle / Ziekenfonds). It involves medical examinations, administrative review, and an assessment of functioning focussing on work capacity. (ii) Income replacement allowance (ARR). It provides income support for people with severe health conditions who are unable to work and have no work history. The assessment is conducted by a medical service of the NIDI. Applications are submitted through the health insurance fund. The assessment includes a medical assessment and its impact on the person’s work potential.

Invalidity pension

Administrative process steps are briefly summarised below (they may take 6‑12 months to complete):

Initial work incapacity (a pre‑pension phase): Paid sick leave verified by a medical certificate for up to 12 months due to an illness/non-occupational injury.

Formal application initiation (month 10‑11 of Incapacity). When a person approaches the 12 months of continuous paid sick leave, the insurance fund automatically initiates the invalidity pension process. A person receives an application dossier (or must request one). The dossier must be completed; the forms have to be filled out and submitted within 30 days.

Dossier submission. The sick person submits the dossier to the health insurance fund. A complete dossier should include medical reports from treating physicians/specialists, work history (employment contracts, tax records), ID proof, national registry number and a completed self-assessment questionnaire (describing functional limitations).

Medical file review by the health insurance fund. The fund reviews the medical file and, if it finds it in order, sends it to FEDRIS for assessment.

FEDRIS medical and functional assessment. A FEDRIS physician reviews the file and schedules a clinical examination, which includes a medical checkup, a review of checking functional limitations (mobility, strength, sensory, cognition, psychosocial), and vocational analysis based on age, education, skills, work experience, adaptability to other jobs, and labour market conditions.

Determination of work incapacity. FEDRIS calculates the person’s loss of earning capacity as a percentage: 33%: Mild (e.g. can work part-time in adapted role); 50%: Moderate (e.g. limited to sedentary work, 3‑4 hours /day); 66%: Severe (e.g. unable to perform any consistent work), and above 66% and dependency: Qualifies for higher pension and supplements. FEDRIS issues a technical-medical report to the person’s health insurance fund. For example: a construction worker with spinal fusion, chronic pain, and limited spinal flexion (MRI-confirmed) who cannot lift more than 5 kg, or stand for more than 20 minutes, or bend will be assessed to have a 66% earning capacity loss unable to return to construction and with no transferable skills.

Health insurance fund decision. The person’s health insurance fund reviews the FEDRIS’ report and checks other eligibility criteria (work history, age) and within 30 days issues a formal decision letter (approves the proposal, rejects it based on insufficient medical proof and/or unmet work history, or changes it by awarding a lower incapacity degree).

Referral to the employment office. Persons with partial work incapacity, are referred to regional employment offices for vocational retraining and/or job placement in “suitable employment” matching residual work capacity. A refusal to participate may reduce or suspend benefits.

Appeals. The decision may be appealed following the legally established process.

The invalidity pension assessment and determination criteria: medical, administrative and functioning. The assessment determines a degree of work incapacity quantified as earning capacity loss.

• Medical Criteria. A person must have clinically diagnosed and verified health condition(s). The health problem must be stable or progressive and has already lasted or is expected to last for more than a 1 year. The person must provide comprehensive records from treating physicians, hospitals, and specialists, as well as critical evidence that functional limitations are linked to the diagnosis (e.g. “Patient cannot stand for more than 10 minutes due to spinal stenosis”).

• Administrative criteria are related to legal and insurance contribution related requirements: (i) work and contribution history; (ii) incapacity duration (must be on a sick leave for 12 months, verified via sickness certificates); (iii) age limit (must be less than 65 years (pension age)). Those aged 65 and over transition to retirement (old age) pensions.

Functional assessment criteria: As part of the assessment of lost earning capacity (%) due to functional impairments, FEDRIS doctors evaluate functional impairments in work-related contexts using clinical examinations and tests to determine impairment (e.g. lifting, walking, concentrating), and a workplace adaptability (Table 3.4).

Table 3.4. Belgium assessment of functional impairment for invalidity pension

Domain	Assessment focus	Concrete examples
Mobility	Walking, standing, climbing stairs	Cannot stand >15 mins; unable to climb stairs without assistance.
Strength	Lifting, carrying, manual dexterity	Max lift capacity: 5kg (vs. 25kg pre‑injury); unable to grasp tools due to arthritis.
Sensory	Vision, hearing	Corrected vision <20/20; cannot hear conversations in noise.
Cognition	Memory, concentration, decision making	Unable to focus >30 mins; fails multitasking tests.
Psychosocial	Stress tolerance, social interaction	Panic attacks in crowds; unable to handle customer complaints.

Source: Compiled by the authors based on the sources provided in the references.

Combining medical and functional assessment: Table 3.5 presents some examples of medical and functional requirements for invalidity pension.

Table 3.5. Invalidity pension – combining medical and functional assessments

Health condition	Medical evidence	Functional impact
Chronic Heart Failure (NYHA Class III/IV)	Echocardiogram showing ejection fraction =35%. Cardiologist report confirming dyspnea at minimal exertion.	Inability to perform any job requiring physical effort (e.g. 66% incapacity).
Stage 3B+ chronic kidney disease	eGFR <45 mL/min persisting >1 year. Dialysis records (if applicable).	Fatigue/nausea limiting work to =3 hours/day (50% incapacity)
Major Depressive Disorder (Recurrent, Severe)	Psychiatric evaluations documenting =2 years of symptoms. Failed trials of antidepressants + psychotherapy.	Cognitive impairment (e.g. inability to concentrate for tasks).

Source: Compiled by the authors based on the sources provided in the references.

Income replacement allowance (ARR/TIV)

Eligibility requirements: To qualify for the income replacement allowance, a person: (i) must be older than 21; (ii) must have permanent disability: more or equal to 65% loss of physical and mental function, assessed using specific scales; disability must be stable, irreversible, or progressive; and must arise before the end of working life. Disabilities covered by occupational injury schemes (managed by FEDRIS), and conditions responsive to short-term treatment (e.g. routine fractures) are excluded; (iii) must have a loss of more or equal to 65% loss in one or more functional domains, measured using physical (mobility, dexterity, sensory function) and mental scale (cognition, communication, behaviour); (iv) is unable to earn more than one‑third of what a non-disabled person could earn in the local labour market; and (v) must not be eligible for other pensions.

Eligibility assessment: The assessment includes the review of medical documents and an evaluation of functional capacity using standardised scales to assess physical and mental functional impairments. This includes on site walking tests, grip strength, balance, endurance and cognitive memory tasks, problem-solving, stress tolerance simulations. In addition, a vocational analysis and an income capacity test are performed. The former includes an evaluation of the residual work capacity to determine whether the person perform any job and an analysis of the local labour market situation, including local job availability, educational and language skills requirements. The latter is an income capacity test that compares potential earnings of the applicant with a non-disabled peer as the benchmark.

Table 3.6 presents several examples of combined medical and functional criteria used for the Income Replacement Allowance.

Table 3.6. Income Replacement Allowance – Combining medical and functional assessment

Health condition	Required medical evidence	Functional threshold
Multiple Sclerosis (MS)	MRI showing demyelinating lesions. Neurologist report documenting progression over ≥2 years.
	≥65% mobility loss (e.g. inability to walk >50m without aid). Severe fatigue preventing sustained activity (>4 hours/day).
Severe Traumatic Brain Injury (TBI)	CT/MRI showing permanent structural damage. Neuropsychological tests (e.g. MMSE <20/30, impaired executive function).	≥65% cognitive loss (e.g. inability to manage personal finances.
Advanced Rheumatoid Arthritis (RA)	Seropositive RF/anti-CCP tests. X-rays showing joint erosion (Stage III/IV).	≥65% upper limb loss (e.g. inability to grasp objects or button clothing).

Source: Compiled by the authors based on the sources provided in the references.

A decision whether a person qualifies for the income replacement allowance is made by the NIDI Medical Board. The decision can be appealed following a standardised procedure.

Regional benefits

These benefits are focussed on integration, support, care, and broader disability recognition and are administered by the regional governments: Flanders (The Flemish Agency for Persons with Disabilities (VAPH)), Wallonia (Walloon Agency for Quality of Life (AViQ)), and Brussels-Capital Region (Iriscare).

Flanders. The VAPH assesses and determines a Support Intensity Level (SIL), which is a precondition for eligibility for VAPH support (personal assistance budget – personalised assistance budget (PAB), residential care, day centres, etc.). The focus is on the needs for support for independence. The main support benefit is a PAB – a cash allocation for individuals to hire personal assistants for support at home, work, or leisure.

Wallonia – The AViQ assesses and determines a Degree of Autonomy (DA), which is a precondition to receive the AViQ’s support benefits (financial aid, technical aids, residential support, etc.). The key criteria are: significant, permanent disability leading to substantial limitations in autonomy and social participation. The main form of support is a personalised assistance budget.

Brussels-Capital Region. Iriscare4 assesses and determines a Support Level (SL) for both language communities in Brussels, determining eligibility for regional support measures (like VAPH/AViQ). The key benefit is a monetary allowance linked to the support level.

Observations

There is no disability determination in Belgium as such. Rather, people with a health condition are assessed for functional limitations in the context of eligibility for monetary benefits and services at the federal and regional levels. The assessments are administered by separate bodies and use different assessment criteria. Qualifying for an invalidity pension (federal) does not automatically qualify a person for regional benefits, and vice‑versa. Individuals often need to apply to both federal and regional systems depending on their needs (income support or care/support services).

Decreased work and earning capacity are assessed and determined within the context of eligibility for invalidity pension and income replacement allowance (two federally funded benefits). Core components of the assessment are medical and “functional”. The former is focussed on establishing and verifying the presence of a health condition. The latter mostly assesses the impact of the health condition on body functions (or impairments of body functions), which is then translated into a person’s capacity to work and earn income, in relation to the person’s job and the situation in the local labour market. This is illustrated by the “functional” assessment criteria for invalidity pension. They are a combination of symptoms (e.g. panic attacks) and an assessment of what the body can or cannot do because of the health condition. In other words, in terms of the ICF classification, the assessment is mostly focussed on body functions, and, hence, it remains mostly medically oriented.

The assessment for the income replacement allowance is guided by extensive and detailed protocols, which distinguish between mental and physical functions (in difference, the ICF classification has no such division, albeit mental functions are part of the body functions classification). The assessment rarely considers the impact of the environment and in that sense does not assess activities limitations and participation restrictions as conceptualised in the ICF, i.e. as difficulties persons with health conditions experience in performing activities and participating is social life in their own environment.

All three Belgian regions (Flanders, Wallonia and Brussels) assess and determine the need for assistance – respectively Support Intensity Level, Autonomy Degree and Support Level. The processes and criteria are similar, and the needs are classified into four levels: mild, moderate, severe and very severe. In all regions, there is a home visit to assess the functional limitations and the need for assistance. As far as the needs assessment is concerned, there has been no empirical assessment and evaluation of the methods used. A different issue is that de facto, the letters issued to applicants informing them about the level of their support needs are considered as formal disability status determination. This is controversial from the conceptual standpoint, because it is disability that should determine the level of needs and not the other way around. A separate issue is that the methods used to assess the needs are not suitable for disability determination.

3.5. Non-European Union case studies

3.5.1. Moldova

In Moldova, as in many other countries, a person with a health condition and/or impairment is required to be formally certified to have a disability to access government support. The current system has been shaped by historical legacy, recent efforts to modernise it are in line with the contemporary understanding of disability and CRPD and ensure its transparency and integrity.

Legal and institutional framework for DA&D

Moldova changed its approach to disability and the way how disability and work capacity are determined in 2012 by adopting the Law on Social Inclusion of People with Disabilities (LSIPD) (Government of Moldova, 2012[27]) and related bylaw (Government of Moldova, 2018[28]). The Law adopted definitions and language from CRPD and WHO’s ICF and instituted disability determination in terms of medical and functioning information.

The reform introduced a single unified disability and work capacity determination process implemented by a newly established dedicated government body – The National Council for Determination of Disability and Work Capacity (NCDDWC) under, at the time, Ministry of Health, Labor and Social Protection. The administrative process was reengineered with the objective to minimise rent seeking opportunities, by, for example, randomly assigning cases to the NCDDWC assessors. The new regulation stipulated that the assessment and determination of disability and work capacity should be based on a comprehensive set of documents that included a description of the person’s state of health, information about functioning (WHODAS for adults, and a 93 item Activities and Participation Questionnaire for children), information from employment and the social assistance offices, information from a responsible psycho-pedagogical assistance service or early intervention service (for children). The information served a dual purpose: to determine the degree of disability and work capacity and to determine the person’s needs. The latter serves as a basis to formulate an Individual Program of Rehabilitation and Social Inclusion (IP). The IP covers needs for medical care and rehabilitation, assistive aid, accommodation, educational needs, social protection needs, and employment support. The certificate of the degree of disability and the IP are issued jointly.

The LSIPD stipulates that “disability determination should be based on the severity of individual’s functioning impairments caused by lesions, disorders, injuries leading to the activities’ limitations and participation restrictions in relation to the person’s socio-professional requirements (maintaining ability to work)”. The three degrees of disability and work capacity are: (i) Very severe disability which is characterised by very severe functional limitations caused by lesions, disorders, and injuries, leading to the activities’ limitations and participation restrictions. Retained work capacity is 0‑20%. Severe and moderate disability are defined in the same way with retained work capacity of 25‑40% and 45‑60%, respectively. Individuals with mild functional impairments whose work capacity is estimated at 65‑100%, are recognised as able to work, and no degree of disability is determined for them.

DA&D administrative procedure and criteria

Administrative procedure

Initiation: Disability assessment is initiated by a healthcare institution that prepares an electronic referral form in the automated health information system. The referral can be prepared only if “obvious indicators of functional disorders of the body persist after applying all appropriate diagnostic, treatment and rehabilitation measures”.

Application & registration: The referral and an application with other mandated documents must be submitted by a person to a NCDDWC territorial structure by their place of residence. The application is formally registered in the NCDDWC information system (IS).

Collection of information on functioning (WHODAS interview): After the registration, a territorial structure’s social relations specialist or a psycho-pedagogue conducts the WHODAS interview. The questionnaire is completed electronically in the IS.

Assignment of assessors: The territorial structures prepare a case file in electronic format and both the electronic and the paper version of the file are sent to the Registration and Archiving Office. The files are then automatically and randomly assigned to the experts of the Service for the Determination of Disability Degree of NCDDWC.

Disability assessment and determination: The assessment is conducted as a desk review by assessors. Assessors are medical doctors. The decision is made by a case manager. The case manager also prepares an Individual Rehabilitation and Social Inclusion Program. The decision on disability determination includes the decision on the disability degree, disability cause, duration of the certificate, general recommendations regarding the activities and services that the person with disability needs in the process of social inclusion, percentage of loss of work capacity because of the work accident or occupational disease (if applicable), and the need for transport (Government of Moldova, 2018[28]).

Disability determination criteria

Determining the degree of work capacity and disability: Relevant regulation stipulates that disability and work capacity should be determined based on medical and functioning information. Both are described in detail in the Methodological Guide (Ministry of Labor, Social Protection and Women; National Council for Disability and Work Capacity Assessment; Ministry of Health; Medical and Pharmacology State University “Nicolae Testemitanu”; the National Public Health Institute, 2014[29]). The regulation stipulates that disability degree or work capacity is assessed by evaluating person’s reduction of vital capacities, basic work capacity and remaining work capacity.

Reduction of vital capacities represents a limitation of vital capacities caused by functional and structural body impairments and is assessed in intervals of 5 p.p. Basic work capacity is calculated as a difference between the total functional potential of the human body (vital capacity = 100%) and the determined percentage of the reduction of vital capacities, resulting from impairments in body functions and body structures, in accordance with detailed standardised criteria presented in the Methodological Guide. Retained work capacity is calculated by multiplying the percentage of basic work capacity with the coefficients (developed by experts).

The medical evaluation requires assessing the state of body structures and body functions: Functional and structural impairments and basic work capacity percentages are determined following detailed tables from the Methodological Guide where the problems in body functions and body structures are meticulously presented following the ICD‑10 groups of diseases.

The assessment of functioning: Moldova uses the World Health Organization’s Disability Assessment Schedule (the 36‑item version, administered by an interviewer) to collect information on functioning, or in terms of the ICF, performance of life activities and participation in society as a true measure of disability. The WHODAS interview is conducted in person, by a staff member of the NCDDWC territorial structure. Each question is rated on a 1‑5‑point scale (1– no difficulty, 2 – mild difficulty, 3 – moderate difficulty, 4 – severe difficulty and 5 – extreme difficulty/cannot do). The interviewer has access to the applicants’ medical and other information. For each interviewed person, a raw WHODAS score is calculated automatically by summing up the ratings of all 36 questions.

Depending on the WHODAS raw score, which is differentiated by employment status, a pre‑determined coefficient is applied to the basic work capacity percentage to determine the percentage of retained work capacity. The coefficients were chosen by experts and are 0.7 for very severe functioning difficulty, 1.0 for severe and 1.3 moderate functioning difficulty. Next, for the coefficient 0.7, each percentage degree of basic work capacity is decreased by 5 p.p., in the case of coefficient 1.0, there is no change and in the case of the coefficient 1.3, each percentage degree of basic work capacity is increased by 5 p.p. This algorithm makes the impact of functioning in determining disability and retained work capacity almost meaningless (in total, about 7.0% of cases are impacted) (Posarac, 2024[30]). For example, in the case where basic work capacity determined based on medical criteria is 60% (indicating a low end of the moderate problem), but WHODAS score suggests very severe functioning problem, the basic work capacity would decrease to 55%, resulting in no change in work capacity degree the work capacity is still almost mildly affected. The only potential impact could be at the border percentages moving a person up or down the degree of disability or work capacity.

Observations

Following the ICF and the CRPD, Moldova adopted a modern legal framework for disability system and policies in 2012/13 and included functioning into DA&D. It chose WHODAS to assess and measure functioning, the only currently available such instrument with empirically proven, publicly known psychometric validity and reliability and interval scale measurement properties. However, in practice, disability is assessed and determined as a medical issue. Based on medical criteria, the percentage of “functional-structural impairments” is determined, which in reverse, i.e. as a difference to 100% of bodily capacity (“vital” capacity), is then determined to represent a “basic work capacity”. In the final instance, predetermined coefficients based on the WHODAS raw scores are applied to the “basic work capacity” to determine the degree of disability and work capacity. The coefficients were developed by experts and are so small that functioning has almost no impact on disability determination.

3.5.2. Uzbekistan

In Uzbekistan, a formally determined disability status is a gateway for accessing publicly provided support. Since the ratification of the CRPD in June 2021, Uzbekistan has been taking steps to systematically include disability in the country systems and policies, including the reform of its disability assessment and determination system.

In July 2024, a presidential decree stipulating several important changes concerning disability assessment and determination and the Medical and Social Expertise Commission’s (MSEC) operations was issued (Government of the Republic of Uzbekistan, 2024[31]). The objectives of the changes are:

• To develop a system for determining disability that will consider the state of health and functioning (activity and participation of a person in daily life).

• To eliminate bureaucratic barriers and opportunities for rent seeking.

• To increase transparency of the process for establishing disability.

• To accurately and timely identify needs of persons with disabilities to improve their quality of life and socialisation.

Thus, Uzbekistan is currently in the process of reforming its DA&D system by transitioning it from a system based on medical assessment alone to one in which disability is understood as the outcome of interaction between a person’s health condition and their environment. To that end, both administrative processes and criteria for disability assessment and determination are currently being changed. Below, the system as it operates currently is described taking into account all changes that have taken place since July 2024.

The current system of DA&D of adults

Administrative process

DA&D of adults is extensively regulated. The key law is the Law on the Rights of Persons with Disabilities (Government of the Republic of Uzbekistan, 2020[32]) that is operationalised through presidential and government decrees.

Medical and Social Expertise Commissions (MSECs) are government bodies tasked with disability assessment and determination. They are a subordinate structure of the National Agency for Social Protection (NASP) and are managed by the NASP’s Department for the Assessment of Functioning. MSEC is organised along the territorial and administrative structure of Uzbekistan and covers the entire country. The MSEC structure is composed of municipal MSECs (consisting of three medical doctors conducting disability assessment and determination); regional MSECs that monitor and control municipal MSECs and serve as resource centres and the Republican MSEC that monitors and guides work of the entire MSEC system.

The disability certification process consists of the medical assessment phase, conducted by the health system and the determination phase conducted by the medical and social expert commissions.

Disability determination can be requested (in person or electronically) by an individual or their representative or a treating medical doctor/institution. The request is forwarded by the social service centres (INSON) to the person’s family doctor who, based on their recent medical history and records and following standardised medical criteria and formats refers the patient to the responsible MSEC using the electronic version of the referral form (Form‑88). This is a major change in the DA&D administrative process implemented during 2024. It required a standardisation and automation of medical criteria, training more than 17 000 family doctors in implementing them and using the electronic referral system, as well as training MSEC doctors in the new system.5 If the referral is accepted by the MSEC (no need for corrections, or additional information) the patient is informed about the appointment with the MSEC. The MSEC examines the patient during a face‑to-face appointment and decides if the person meets disability determination criteria. It also determines a degree of disability, duration of the certificate and recommends assistive devices, further medical treatment, rehabilitation and a third-party assistance/care for the Group I persons with disabilities (described below).

The MSEC conclusions are communicated to the patient, including a mandatory explanation of the conclusions. A certificate of disability is issued in electronic form immediately, certified by a QR code.

Criteria

The determination of disability and its degree is made considering a clinical course of the main disease, its complications and clinical and expert prognosis. Disorders and impairments of body functions are linked to a disease and classified by degrees: Stage I (minor disorders), Stage II (moderate disorders), Stage III (pronounced disorders) and Stage IV (severe disorders). MSEC has a methodological guide that contains a long list of health conditions with ICD‑10 codes and detailed description of body function impairments by degrees for each disease. Based on the degree of the impairments of body functions a degree of disability is determined: a Very Severe (Group I) Disability in the case of persistent very severe impairments of body functions; Severe (Group II) Disability in the case of persistent severe impairments of body functions; and Moderate (Group III) Disability in the case of persistent moderate impairments of body functions.

Hence, currently, disability in Uzbekistan is determined based on standardised and automatic medical criteria. Until April 2024, the criteria also included limitations of life activities that the MSEC doctors would infer based on the patient’s medical condition, without considering the impact of the person’s environment. Moreover, the limitations in life activities were differentiated based on the need for assistance, which is conceptually questionable, given that it is disability that determines the needs, not the other way around. As part of the reform, it was decided to no longer take into account the life activities limitations determined in this way. Instead, Uzbekistan has been pilot testing an instrument to assess and measure functioning that includes WHODAS 36 plus seven questions added by the NASP experts.

Uzbekistan’s instrument to assess and measure functioning (WHODAS 36+7) was initially pilot tested at the end of 2024. More than 3 000 interviews with applicants for disability determination were conducted. The data was analysed for psychometric properties and found that the instrument is valid, reliable, reflects the construct of disability and the scale has interval scale measurement properties. Based on the results, the NASP made the decision to collect functioning information across the entire country. At the end of 2025, a data base of more than 53 000 cases was analysed and empirically derived options to include functioning into disability determination were proposed to the NASP management. It is expected that the functioning will be included in DA&D on 1 January 2027.

Observations

Uzbekistan is in the process of systematically reforming its disability assessments and determination system with the objective of developing a system that will include functioning. The reform is broad and deep, and it includes: (i) improvements to and, standardisation and automation of medical criteria; (ii) revision and automation of administrative and business processes; (iii) extensive staff capacity development, including training of more than 17 000 family doctors, more than 500 officers to administer WHODAS + 7; more than 500 employees of the MSEC and thousands of other professionals from the social protection sector to inform them about modern understanding of disability and functioning; and (iv) pilot-testing and analysing data on functioning to derive empirically founded options on how to include functioning into disability determination.

3.5.3. United States: including functioning into the assessment system for veterans

Background

In January 2017 the U.S. Department of Veterans Affairs (VA) introduced WHODAS as a required standardised component of the Compensation & Pension (C&P) examination Disability Benefits Questionnaire (DBQ), specifically for Post-Traumatic Stress Disorder (PTSD) claims. This was part of an effort to standardise the assessment of limitations in functioning related to mental health conditions experienced by veterans. By October 2017, the use of the WHODAS was expanded to be a required part of the DBQ for all mental health conditions (not just PTSD) undergoing C&P examination for disability compensation purposes.

The WHODAS was introduced with the following objectives in mind:

• Standardisation: To provide a consistent, internationally recognised, and validated method for measuring functioning across various life domains (understanding and communicating, getting around, self-care, getting along with others, life activities, participation in society).

• Objective measurement: To complement clinical judgment with a standardised tool for assessing how a veteran’s condition impacts their daily life and ability to function.

• Alignment with modern practices: To move towards more objective, functioning assessment criteria in line with contemporary disability frameworks.

The VA uses a 36‑item interviewer-administered version of the WHODAS. The interview is conducted by a trained clinician (e.g. a psychologist, psychiatrist, or other C&P examiner). The examiner guides the veteran through all 36 questions. Responses are scored on a 5‑point scale (from “none” to “extreme/cannot do”). Results are recorded directly in the Disability Benefits Questionnaire (DBQ) for mental health. The interviewer calculates the score and translates it into a score on a 0‑100‑point scale, following the VA methodological guidance, where scores for each domain and an overall WHODAS score are calculated.

The WHODAS score is not the sole determinant of disability ratings – instead, it provides objective evidence on limitations in functioning that clinicians combine with other data to assign a VA disability rating (0%, 10%, 30%, 50%, 70%, or 100%). Thus, the WHODAS score informs and supports the judgement but does not override it.

Assessment criteria and the role of WHODAS

The final ratings follow VA’s General Rating Formula for Mental Disorders, which defines six rating levels based on occupational and social impairment (Table 3.7).

Table 3.7. General Rating Formula for Mental Disorders in the US system for veterans

Rating	Description
0%	A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication.
10%	Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication.
30%	Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behaviour, self-care, and conversation being normal).
50%	Occupational and social impairment with reduced reliability and productivity… (For full description see the source.)
70%	Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood… (For full description see the source.)
100%	Total occupational and social impairment… (For full description see the source.)

Source: 38 CFR §4.130. https://www.ecfr.gov/current/title-38/chapter-I/part-4/subpart-B/subject-group-ECFRfa64377db09ae97/section-4.130.

WHODAS is used in VA disability evaluation to: (i) measure and express quantitively limitations in functioning; (ii) standardise limitations assessments across examiners, and (iii) support clinical judgment when assigning VA disability. WHODAS scores do not determine a specific rating but provide supporting evidence. The examiner compares WHODAS results with VA’s mental health rating schedule (Table 3.8):

Table 3.8. The examiner compares WHODAS results with VA’s mental health rating schedule

WHODAS score range (points)	Typical VA rating	Functioning impairment level
0‑25	0‑30%	Mild (minimal impact on work/social life).
25‑50	50%	Moderate (reduced work efficiency, frequent distress).
50‑70	70%	Severe (inability to work, social isolation).
70+	100%	Total impairment (unable to perform self-care).

Source: Compiled by the authors based on the sources provided in the references.

Clinicians analyse domain-specific patterns to anchor impairment levels (Table 3.9):

Table 3.9. Anchoring WHODAS and impairment levels

Domain	50% rating example	70% rating example	100% rating example
Self-Care	Needs reminders for hygiene	Skips bathing for 3+ days	Requires full assistance
Life Activities	Misses 1‑2 deadlines/week	Cannot sustain employment	Unable to prepare food
Getting Along	Avoids colleagues when anxious	Frequent conflicts/few friends	Isolated; threatens others
Participation	Rarely attends gatherings	Never leaves home voluntarily	Actively dangerous in public

Source: Compiled by the authors based on the sources provided in the references.

In addition, there are also WHODAS domains that are given higher weight for certain ratings. For example:

• VA rating of 50% (moderate functioning impairment level) requires moderate and lower difficulty in “Life Activities” (work) and “Getting Along” (relationships) scores.

• VA rating of 70% (severe functioning impairment level) require severe limitation in “Participation” (community) or “Selfcare”.

• VA rating of 100% (total impairment) requires very severe (cannot do) limitations in “Selfcare” and “Getting along”.

Finally, there are overrides and adjustments:

• Employment status: Working veterans rarely get more than 50% unless WHODAS results in more than 60 points, showing extreme difficulty in functioning. (If WHODAS suggests 50% but the veteran is employed, the examiner may adjust to 30%.)

• Clinician notes: Suicidal ideation or hospitalisation can override WHODAS. If WHODAS is low (e.g. 30) but the veteran is homeless due to mental illness, the examiner may assign 70%.

• Comorbidities: Physical health issues may increase scores. The cases of comorbidities are complex and are subject to separate assessments.

The last one is particularly interesting because separating the impact on functioning of mental health from physical health is difficult to do in practice, both for clinicians and the veterans. In both cases, disability arises, not just from the underlying health problem, but the environment in which the person acts. The same disability might arise from either a mental health or a physical health problem, depending on the environment, so the nature of the health problem does not determine the nature of the disability. A practical solution would be to use WHODAS for all health conditions experienced by veterans.

Results from empirical studies

Since 2017, when WHODAS was introduced, empirical studies have been conducted. Below, some key findings are summarised:

Psychometric strengths & validation: empirical studies have confirmed high psychometric validity and reliability of WHODAS.

Implementation challenges: There are several aspects of how the WHODAS interview is conducted and how the WHODAS scores (a general score and scores by domains) are considered in the final decisions on disability that might be adversely impacting the role the WHODAS is playing.

• Interviewer drift: 30% of clinicians deviate from scripted questions (e.g. rephrasing “participation in society” as “attending church”).

• Scoring errors: some examiners miscalculate prorated (in case of missing data) domain scores; some clinicians who know veterans’ service records assign WHODAS scores 7‑10 points higher. All these problems point to the need for the interviewers to strictly follow instructions on how to carry out the WHODAS interview, as well as to the merits of an automated score calculation. The latter will also enable to trace and monitor the adjustments made by the clinicians.

• Treatment of comorbidity (comorbidity penalty): In cases of comorbidity, clinicians are given a discretion to adjust the WHODAS ratings. The adjustments are not regulated and are left to clinicians’ discretion. Empirical studies show that veterans with chronic pain or traumatic brain injury score 11‑15 points higher on WHODAS even when mental symptoms are controlled. This is to be expected, because separating the impact in the case of comorbidities is very hard. A similar problem is observed in the case of veterans older than 65 years of age. They score higher in mobility and selfcare domains, leading to higher overall WHODAS scores, despite lower percentage of mental impairment severity. This is also to be expected, as ageing naturally leads to decreased mobility and higher difficulties with self-care (there is no information whether there is a discretionary adjustment in such cases).

• Different weighting of domains: “Life activities" (work), Selfcare and Participation drive ratings more than the other three domains (Cognition, Mobility and Getting along). It is not clear how and why these three were chosen.

• Wide discretion of clinicians: (i) No VA algorithm translates WHODAS scores into ratings; it relies on examiner narratives. (ii) Clinical and qualitative exam notes (e.g., “veteran threatened coworkers”) override WHODAS scores for 100% ratings. (iii) Process inconsistency: 22% of high WHODAS scores (>60) receive 50% ratings if: veteran is employed, or examiner attributes impairment to “non-compensable” factors (e.g. personality disorder). (iv) Examiner discretion in interpreting responses (e.g. “moderate” vs. “severe”) creates variability. (Examiners may interpret scores differently (e.g. a WHODAS of 45 could be rated 50% or 70%.)

• Clinical judgment (medical assessment) prevails: WHODAS data is interpreted alongside symptom severity (e.g. frequency of panic attacks, hallucinations), and medical records and exam observations. Often, medical data prevails: A veteran with severe symptoms (e.g. daily flashbacks) but moderate WHODAS scores could still receive a 70%+ rating.

These various discretionary elements in the final decision making are reflected in the following: VA’s WHODAS data show strong correlation with symptoms’ severity, but moderate correlation with final ratings.

Observations

The use of WHODAS by the VA to determine disability and eligibility for benefits of veterans with mental health conditions has justified itself by empirically confirmed strong psychometric validity and reliability.

The VA specific method of WHODAS implementation has raised several important issues:

• Interviewers/examiners must follow closely instructions on how to conduct the WHODAS interview.

• VA uses WHODAS for mental health conditions only. WHODAS is an instrument that performs equally strongly in case of all health conditions. It was designed to assess and measure functioning irrespective of the type of health problem. Expanding it to all health conditions or applying it to mental health conditions as primary (with comorbidities as secondary) would easily resolve the observed issue of comorbidities.

• The non-trivial level of discretion over the use of WHODAS scores undermines the objectivity and accuracy of the determination and often results in higher weight given to medical conditions rather than functioning. Adopting an algorithm to combine medical and functioning assessment with few special cases would improve the objectivity and accuracy of the determination.

3.6. Lessons learned

Some of the key lessons from the case studies:

• It has been scientifically shown, based on extensive empirical studies, that including functioning into disability determination improves its validity, reliability, accuracy, objectiveness, fairness and transparency – all of which ensures the credibility of the disability assessment and determination system.

• It is imperative that the instrument used to assess functioning is tested for psychometric validity and reliability and has the capacity to generate interval scale measurement properties. Only such an instrument can truly assess and measure functioning.

• Reliance on the qualitative scale of “no, mild, moderate, sever and very severe difficulty in functioning” leads to arbitrariness and lack of transparency, and potential fraud.

• It is important to use standardised methods to assess the difficulties in body functions and structures, or impairments, to supplement the purely medical diagnosis. Impairments are the immediate consequences of health problems, and as such are important predictors of problems in more complex activities and areas of participation. Moreover, some underlying health problems, e.g. blindness, can only be expressed in terms of impairments if there is no underlying health condition. This can entail a table where each health condition with its ICD code is linked to ICF “b” codes (body functions) potentially impaired by the said health condition and description of levels of impairment (no, mild, moderate, severe and very severe problem).

• Ultimately, it is a political decision how medical and functioning assessments are combined or used together for a disability assessment. There are various ways to do this, but whatever technique is used it should be clearly spelled out, ideally automated and require minimal discretion. For example, medical information could be used to triage people for whom functioning would be assessed and disability for eligibility for benefits would be determined based on the functioning score. Alternatively, the medical and functioning assessment scores could be combined if relatively similar, or if they were too far apart, one or the other could be used on its own for the decision. Other methods could be designed as well, depending on the context and the purpose of the assessment and determination.

References

[34] ANED (2019), Country report on Disability Assessment - Belgium, https://www.disability-europe.net/country/belgium (accessed on 13 February 2026).

[22] ANED (2019), Estonia - Country Report on Disability Assessment, https://www.disability-europe.net/country/estonia (accessed on 4 February 2026).

[33] APA (2022), Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), American Psychiatric Association, Arlington, VA, https://doi.org/10.1176/appi.books.9780890425787.

[1] Bickenbach, J. et al. (2015), Assessing Disability in Working Age Population: A Paradigm Shift from Impairment and Functional Limitation to the Disability Approach, World Bank, Washington, DC, https://doi.org/10.1596/22353.

[35] Bovin, M. et al. (2019), “Using the World Health Organization Disability Assessment Schedule 2.0 to assess disability in veterans with posttraumatic stress disorder”, PloS one, Vol. 14/8, https://doi.org/10.1371/journal.pone.0220806.

[5] Chiu, T. et al. (2014), “Development of traditional Chinese version of World Health Organization Disability Assessment Schedule 2.0 36 - item (WHODAS 2.0) in Taiwan: Validity and reliability analyses”, Research in Developmental Disabilities, Vol. 35/11, pp. 2812-2820, https://doi.org/10.1016/j.ridd.2014.07.009.

[4] Chiu, W. et al. (2013), “Implementing disability evaluation and welfare services based on the framework of the International Classification of Functioning, Disability and Health: experiences in Taiwan”, BMC health services research, Vol. 13/1, https://doi.org/10.1186/1472-6963-13-416.

[9] Chi, W. et al. (2020), “The inhibiting effects of resistance to change of disability determination system: a status quo bias perspective”, BMC Medical Informatics and Decision Making, Vol. 20/1, p. 82, https://doi.org/10.1186/s12911-020-1090-7.

[8] Chi, W. et al. (2013), “Developing a disability determination model using a decision support system in Taiwan: A pilot study”, Journal of the Formosan Medical Association, Vol. 112/8, pp. 473-481, https://doi.org/10.1016/j.jfma.2013.06.005.

[36] Dennis, P. (2023), “Comorbidity contamination in WHODAS 2.0 scores among veterans with posttraumatic stress disorder and substance use”, Psychological Assessment,, Vol. 35/3, pp. 234-245.

[23] Estonian Social Insurance Board (2023), Determining the severity of a disability of working-age people, Sotsiaalkindlustusamet, https://sotsiaalkindlustusamet.ee/en/disability-and-welfare-services/determination-disabilities/determining-severity-disability-working (accessed on 4 February 2026).

[21] Estonian Social Insurance Board (2023), Determining the severity of disability of a person of retirement age, Sotsiaalkindlustusamet, https://sotsiaalkindlustusamet.ee/en/disability-and-welfare-services/determination-disabilities/determining-severity-disability-person (accessed on 4 February 2026).

[25] Estonian Unemployment Insurance Fund (n.d.), Assessment of work ability, https://www.tootukassa.ee/en/services/assessment-work-ability (accessed on 4 February 2026).

[37] Federal Agency for Occupational Risks (FEDRIS) (n.d.), Federal Agency for Occupational Risks, https://www.fedris.be/fr (accessed on 13 February 2026).

[14] Fellinghauer, C. et al. (2022), Options for Including Functioning into Disability and Work Capacity Assessment in Latvia, World Bank Group, Washington, D.C., http://documents.worldbank.org/curated/en/099310406132218525.

[16] Goverment of Lithuania (1991), “The Law of the Republic of Lithuania on Social Integration of Persons with Disabilities”, https://www.e-tar.lt/portal/lt/legalActEditions/TAR.199156E4E004?faces-redirect=true (accessed on 4 February 2026).

[26] Government of Estonia (2016), “Puude raskusastme tuvastamise tingimused ja kord ning puudega tööealise inimese toetuse tingimused–Riigi Teataja”, https://www.riigiteataja.ee/akt/101032016011 (accessed on 4 February 2026).

[19] Government of Estonia (2014), “Work Ability Allowance Act”, https://www.riigiteataja.ee/en/eli/ee/Riigikogu/act/509072025002/consolide (accessed on 4 February 2026).

[20] Government of Estonia (1999), “Social Benefits for Disabled Persons Act”, https://www.riigiteataja.ee/en/eli/ee/Riigikogu/act/518122025004/consolide (accessed on 4 February 2026).

[13] Government of Latvia (2014), Regulation Regarding the Criteria, Time Periods and Procedures Determining Predictable Disability, Disability, and the Loss of Ability to Work, https://likumi.lv/ta/id/271253-noteikumi-par-prognozejamas-invaliditates-invaliditates-un-darbspeju-zaudejuma-noteiksanas-kriterijiem-terminiem-un-kartibu (accessed on 4 February 2026).

[12] Government of Latvia (2010), “Invaliditātes likums”, https://likumi.lv/ta/id/211494-invaliditates-likums/ (accessed on 4 February 2026).

[17] Government of Lithuania (2025), “Order No. A1-78 / V-179 on The Approval of Criteria for Work Capacity and the Procedure for the Assessment of Work Capacity (with amendments)”, https://www.e-tar.lt/portal/lt/legalAct/TAR.D1F619C285A0/asr (accessed on 4 February 2026).

[28] Government of Moldova (2018), “Government Decision No. 357 on the Determination of Disability”, The Official Gazette 126-132, https://www.legis.md/cautare/getResults?doc_id=119169&lang=ro/ (accessed on 4 February 2026).

[27] Government of Moldova (2012), “The Law on Social Inclusion of People with Disabilities”, https://www.lawyer-moldova.com/2012/08/law-on-social-inclusion-of-people-with.html/ (accessed on 4 February 2026).

[31] Government of the Republic of Uzbekistan (2024), “The Decree of the President of the Republic of Uzbekistan No 257”, https://lex.uz/docs/7021653 (accessed on 4 February 2026).

[32] Government of the Republic of Uzbekistan (2020), “The Law of the Republic of Uzbekistan No. ZRU-641”, https://lex.uz/docs/5694817 (accessed on 4 February 2026).

[6] Huang, S. et al. (2016), “Functioning and disability analysis by using WHO Disability Assessment Schedule 2.0 in older adults Taiwanese patients with dementia”, Disability and rehabilitation, Vol. 38/17, pp. 1652-1663, https://doi.org/10.3109/09638288.2015.1107636.

[38] Iriscare (n.d.), Main page, https://www.iriscare.brussels/fr/ (accessed on 13 February 2026).

[10] Liao, H. et al. (2022), “Factor Structure of an ICF-Based Measure of Activity and Participations for Adults in Taiwan’s Disability Eligibility Determination System”, Frontiers in rehabilitation sciences, Vol. 3, https://doi.org/10.3389/fresc.2022.879898.

[39] Marx, B. et al. (2015), “Using the WHODAS 2.0 to Assess Functioning Among Veterans Seeking Compensation for Posttraumatic Stress Disorder”, Psychiatric services (Washington, D.C.), Vol. 66/12, pp. 1312-1317, https://doi.org/10.1176/appi.ps.201400400.

[29] Ministry of Labor, Social Protection and Women; National Council for Disability and Work Capacity Assessment; Ministry of Health; Medical and Pharmacology State University “Nicolae Testemitanu”; the National Public Health Institute (2014), Criteria for the Assessment of Functioning and Determination of Disability and Work Capacity, Methodological Guide.

[24] Ministry of Social Affairs (2020), Methodology for the Assessment of Work Ability, https://www.tootukassa.ee/en/services/assessment-work-ability (accessed on 4 February 2026).

[40] Monson, C. (2022), “A comparison of quality of life and psychosocial functioning in posttraumatic stress disorder and depressive disorders”, Journal of Psychiatric Research, Vol. 145, pp. 334-340.

[41] National Institute for Sickness and Invalidity Insurance (n.d.), Acceuil, https://www.inami.fgov.be/fr (accessed on 13 February 2026).

[42] Pietrzak, R. (2020), “Cross-cultural validation of the inventory of psychosocial functioning in veterans”, Journal of Psychopathology and Behavioral Assessment, Vol. 42/4, pp. 639-648.

[30] Posarac, A. (2024), Moldova: Disability system and policy review, World Bank.

[15] Posarac, A. and J. Bickenbach (2020), Lithuania - Disability Policy and Disability Assessment System, World Bank Group, Washington, D.C., http://documents.worldbank.org/curated/en/099310106132231429.

[11] Posarac, A., E. Celmina and J. Bickenbach (2020), Latvia – Disability Policy and Disability Assessment System, World Bank Group, Washington, D.C., http://documents.worldbank.org/curated/en/099310306132234252.

[18] Posarac, A., C. Fellinghauer and J. Bickenbach (2021), Options for Including Functioning into Disability and Work Capacity Assessment in Lithuania, World Bank Group, Washington, D.C., http://documents.worldbank.org/curated/en/099310106132229174.

[50] Possemato, K. (2018), “Outcomes associated with the VA’s implementation of the WHO Disability Assessment Schedule 2.0 as a PTSD functional impairment screening tool.”, Psychological Services, Vol. 15/1, pp. 100-107.

[43] Rotenstein, L. (2020), “Clinician familiarity with veterans’ service histories influences disability ratings”, Psychological Services, Vol. 17/3, pp. 348-356.

[44] Service Public Fédéral Sécurité Sociale (2023), “Rapport annuel 2023”.

[45] Service Public Fédéral Sécurité Sociale (n.d.), Everything you always wanted to know about Social Security.

[46] Sexton, M. et al. (2019), “A factor analytic evaluation of the World Health Organization Disability Assessment Schedule 2.0 among veterans presenting to a generalist mental health clinic”, Psychiatry Research, Vol. 272, pp. 638-642, https://doi.org/10.1016/j.psychres.2019.01.008.

[7] Teng, S. et al. (2013), “Evolution of system for disability assessment based on the International Classification ofFunctioning, Disability, and Health: A Taiwanese study”, Journal of the Formosan Medical Association, Vol. 112/11, pp. 691-698, https://doi.org/10.1016/j.jfma.2013.09.007.

[47] The Flemish Agency for Persons with Disabilities (n.d.), Homepage, https://www.vaph.be/ (accessed on 13 February 2026).

[48] U.S. Department of Veterans Affairs (2025), Public Disability Benefits Questionnaires (DBQs), https://www.benefits.va.gov/compensation/dbq_publicdbqs.asp (accessed on 13 February 2026).

[3] United Nations (n.d.), Convention on the Rights of Persons with Disabilities (CRPD) | Division for Inclusive Social Development (DISD), https://social.desa.un.org/issues/disability/crpd/convention-on-the-rights-of-persons-with-disabilities-crpd (accessed on 4 February 2026).

[49] Walloon Agency for Quality of Life (AViQ) (n.d.), Homepage, https://www.aviq.be/fr (accessed on 13 February 2026).

[2] WHO (2018), International Classification of Functioning, Disability and Health (ICF), https://www.who.int/standards/classifications/international-classification-of-functioning-disability-and-health (accessed on 4 February 2026).

Notes

← 1.  For example, the conditions and procedure for determining the degree of disability are stipulated by a Decree of the Minister of Social Affairs No. 18 (Government of Estonia, 2016[26]) from 29 February 2016 as one of the implementing regulations of the Social Benefits for Disabled Persons Act. Subsequently amended.

← 2.  In The Methodology for the Assessment of Work Ability (2020[24]) in the Definitions section, Incapacity for work is defined as “a person is incapable of working, taking into account his/her state of health, ability to perform activities and the resulting restrictions on activity and participation, their prognosis and expected duration”. Also, as “incapacity for work” means a particularly serious and unchanging medical condition which results in total incapacity for work.

← 3.  The Ministry of Social Affair’s Methodology states that “While the claimant's assessment of his or her functional capacity is very important, the person's testimony must be corroborated by medical evidence.”

← 4.  Iriscare is the name of a bi-communal public interest organisation in Brussels, Belgium, responsible for various aspects of social protection within the Brussels-Capital Region. It acts as a central point of contact for citizens and professionals regarding social security matters, including assistance for the elderly, people with disabilities, nursing homes, home help services, and child benefits.

← 5.  Previously, a treating physician or medical institution based on the patient’s health state referred the patient to a medical advisory commission (MAC) at the local health clinic for examination. This commission consisting of three medical doctors would examines the patient, her/his medical history and available medical documentation and, if deemed applicable, would refer the patient to a relevant MSEC for disability determination.