World Blind Union position on International Classification of Functioning

ICF belongs to the family of classifications developed by the World Health Organization for application to various aspects of health. It classifies functioning and disability as associated with health conditions and is complementary to the International Classification of Diseases (ICD). It applies to all people and not only to people with disabilities, which is a widely held misconception. In other words, its application is universal.

History

In 1980 the World Health Organization first published an International Classification of Impairments, Disabilities, and Handicaps (ICIDH). ICF represents a revision of that text. During the drafting stages and field trials the document was entitled ICIDH-2: International Classification of Functioning and Disability, for historical reasons. In the final version, however, this has been changed to International Classification of Functioning. This is the version adopted by the World Health Assembly in May 2001.

Aims

The aims of ICF can be summarised as follows:

• to provide a scientific basis for understanding functional states associated with health conditions;
• to permit comparison of data across countries, health care disciplines, services, and time: and
• to provide a systematic coding scheme for health information systems.

Dimensions

ICF has three dimensions: body function and structure, activity, and participation. Contextual factors are an integral component of the classification and consist of Environmental Factors (external) and Personal Factors (internal).

The term "dimension" refers to levels of functioning. The dimensions are conceived as having two poles: At the one end they can be used to indicate problems (e.g. impairment, activity limitation or participation restriction); at the other end they can indicate non-problematic (i.e. neutral and positive) aspects of functioning. "Functioning" is used as an umbrella term for the positive or neutral aspects of dimensions at body, individual or society level. "Disability" is used as an umbrella term for the problems in these dimensions.

Models

Here the term "model" is used in the sense of a construct or paradigm. Various conceptual models have been proposed to understand disability and functioning. These may be expressed in a dialectic of "medical model" versus "social model".

The medical model views disability as a personal problem directly caused by disease, trauma or other health conditions. What is required is medical care by professionals.

The social model of disability, on the other hand, considers the problem to be socially created. The response has to be social action to achieve the full integration of individuals into society.

Now the ICF proposes a synthesis of these two models, advocating a so-called "biopsychosocial" approach. It seeks to provide a coherent view of different dimensions of health at the biological, personal, and societal levels.

Levels

ICF exists in two versions, long and short. In the long version there are four levels of classification, which in the short version are reduced to two levels, these being our focus here.

Remembering that there are three dimensions - body function and structure, activity, and participation - a one-level classification indicates, for example, that there is a sensory problem, say, of seeing or hearing, and that this causes certain activity limitations (in moving around, for example), and participation restrictions (in employment, for instance).

A two-level classification indicates the extent of the problem, expressing it in the form of an alphanumeric code. In addition, environmental factors can be similarly coded. This coding of dimensions and components can also be positive, for example, where the environment is accessible.

Uses

Various examples are given of the use of the classification since the publication of the first version in 1980. I give below the three most obvious uses:

• as a statistical tool;
• as a research tool; and
• as a social policy tool.

WBU Viewpoints

I suggest that the WBU adopt the following viewpoints in relation to the ICF:

• that there is a need for an international classification relating to disability and health conditions;
• that the existing classification (the ICF) is overdependent on professionals and overreliant on unconstrained budgets, which is a serious disadvantage in developing countries;
• that the World Health Organization be encouraged to resource a training programme enabling developing countries to make more effective use of the ICF;
• that while the current classification has some merit and usefulness, the WBU cannot endorse any instrument in the development of which it was not consulted;
• that, despite its reservations, the WBU will maintain an interest in the existing classification because of the need to monitor any enterprise where blind people are classified or made the subject of data collection;
• that while the relevance of a medical paradigm is acknowledged in the health sector, the WBU chooses to apply a human rights paradigm in its own programmes, policies, and advocacy work; and
• that any classification conceptualising disability as problematic detracts from the image of disabled people and that, therefore, there is a need to develop an alternative classification in partnership between the World Health Organization and the international disability rights movement. A classification rating human potential presents itself as one such possibility.

Author's Note

In this short paper I have tried to reduce eight braille volumes of highly technical material to an understandable description of the ICF. Nevertheless, the retention of some technical terms has been unavoidable, while the complexity of the ICF remains more than apparent.

Cross-reference

Other information relevant to the measurement of disability is given in the WBU position paper entitled Definition of Blindness.

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