Disability Inclusion and Pandemic Policymaking in South Africa: A Framework Analysis

COVID-19 in South Africa

The first case of COVID-19 in South Africa was diagnosed on March 5^th, 2020, and a State of Disaster was declared on March 26^th, giving the government extended powers to pass regulations and directions with the aim of managing the crisis [Supplementary File 1, item 2.1.1.]. The initial government response was a hard lockdown which confined everyone but essential workers to their homes for a period of five weeks [Supplementary File 1, items 2.1.3. & 2.1.9.]. Even as these regulations were eased, the government maintained a high degree of control over population movement and activities, and the State of Disaster was only lifted two years later, in April 2022. Significant criticisms have been raised regarding the rationality and transparency of government decision-making during this period, especially given the severe economic and social impact of lockdown measures (Ministerial Advisory Committee on COVID-19 2020; Blecher et al. 2021; Venter et al. 2022).

South Africans with disabilities were affected more severely and intensely than the general population by COVID-19 restrictions imposed to curb the spread of the virus. Inadvertent discrimination materialised against people with disabilities under lockdown restrictions when disability services were initially not classified as essential (McKinney et al. 2021). Lockdown regulations also presented increased barriers to persons with disabilities when the public was only allowed to leave their homes for limited periods, and persons with disabilities had to navigate further restrictive and inaccessible public transport systems to reach shops or health services (McKinney et al. 2022). People with certain disabilities endured higher risk of contracting the virus due to, for example, their need to use touch to navigate spaces, or when utilising structures or equipment for support with mobility impairments (ibid).

Document search and selection

The thematic framework guided our search and selection of policy documents. Documents were included that:

• Had bearing on the national government’s COVID-19 response with respect to health and healthcare;

• Either made direct or indirect provisions for people with disabilities

• Or addressed a significant issue reflected in the analytical framework, whether or not any consideration of people with disabilities appeared;

• Were produced by government departments and bodies (i.e. not disabled people’s organisations or other civil society groups);

• Were produced between March and December 2020.

Although the Department of Health (DOH) was our starting point, the elements of the framework involved action from several other departments as well. The core set of regulations governing the national lockdown were issued by the Department of Cooperative Governance and Traditional Affairs (COGTA), which was the ministry designated to lead the disaster response. Other relevant departments included the Departments of Social Development (DSD), Transport (DOT), Telecommunications and Postal Services (DTPS), and Employment and Labour (DEL). We excluded documents dealing specifically with education and educational institutions due to time constraints.

We began by searching the national government’s official coronavirus website, and the sites of specific ministries relevant to our research question (see Supplementary File 2: Websites Used in Document Search). We screened all available policy and related documents from the inclusion period and downloaded the selected material for analysis. We also cross-referenced document lists appearing on different sites to ensure comprehensive coverage. Some of the included documents referenced further material not identified through our search, and these were then sourced where possible. All sources were accessed in their original language, which was English.

A range of document types were found in our search, with differing degrees of legal status. The Disaster Management Act (Government of South Africa 2002) empowered the government to make regulations and issue directions to deal with the pandemic. Regulations were legally binding on all citizens, government departments, and organisations, while directions were confined to the specific remit of the issuing Cabinet minister (Government of South Africa 2002). Guidelines further fleshed out how regulations and directions should be implemented, but were not legal imperatives. Speeches and media releases had no legal status but added to our understanding of the overall government discourse and gave some information on actions taken.

Regulations and directions did not cover all of the elements of the thematic framework. We therefore extended our search to documents not necessarily issued directly by government, but likely to shape action in key areas. For example, the issue of telehealth during the pandemic was addressed primarily by guidelines from the Health Professions Council of South Africa, the statutory body regulating the registration, conduct, and practice of health professionals. We also chose to include documents produced by the Ministerial Advisory Committee on COVID-19 (MAC), a group of leading scientists and clinicians appointed by government to interpret emerging evidence on the pandemic and inform decision-making. Even though advisories from the MAC had no regulatory power, they provided insight into the rationale behind some government decision-making.

Document search and review were undertaken by two researchers independently (one after the other), to ensure comprehensive coverage. Uncertainties about inclusion were discussed and resolved together, with no disagreements noted. Table 2 below summarises the documents finally included in the study.

Data analysis

Our analysis broadly followed the five steps outlined by Ritchie and Spencer (1994), namely familiarisation, identifying a thematic framework, indexing, charting, and mapping. As explained above, we began with the thematic framework and used this to guide our document search. Familiarisation then involved an initial reading of all of the documents. The next step was indexing the documents’ content against the thematic framework, followed by charting, in which we extracted specific data against each theme. This allowed us to identify gaps and overlaps in the themes, leading to further clarification of the thematic framework and some additional sourcing of material. The last stage, mapping, identified the further themes and patterns across the data.

Ethical considerations

This research forms part of a larger study for which ethical clearance was obtained from the Stellenbosch University Social, Behavioural and Education Research Ethics Committee (REC: SBE), Project Number 15244. No specific ethical issues were identified in the document review, as all data is in the public domain and involves no personal or sensitive information.

1. Ensure accessible public health information

Regulations issued by DTPS assigned responsibility for disseminating information about COVID-19 to various role players in the sector [Supplementary File 1, item 5.1.1]. Accessibility provisions in these regulations were limited. All licensed broadcasters were required to receive and disseminate information about COVID-19, “in all local languages as well as sign language” [Supplementary File 1, item 5.1.1:6]. South African Sign Language (SASL) interpreters were used when speeches from the President were broadcast, but not consistently across other programming. Closed captions and subtitles were not made available, and the primary language in which key information was communicated was English.

All local websites were required to display a link to the official government coronavirus website, which posted up-to-date information relating to the virus and the lockdown [Supplementary File 1, item 5.1.1]. This included all regulations, directions, and guidelines promulgated under the Disaster Management Act to date, as well as fact sheets and links to other information sources. The site has no evident accessibility features, although documents can be downloaded in PDF format. Most of the information is provided in English, although some basic fact sheets appeared in other languages. No content was adapted for easy reading. The site did include a disability section, which consisted almost entirely of links to websites of local and international organisations sharing disability-specific information about the pandemic [Supplementary File 1, item 4.3.1]. We found no government documents or sources which presented public health information specifically for people with disabilities.

Access to public health information was facilitated by the zero-rating of the official website, as well as a number of local health and education sites [Supplementary File 1, items 5.1.1 and 5.1.5]. Data costs are a significant barrier to information access for many in South Africa, alongside access to internet-enabled devices, electricity, and network coverage (especially in rural areas) (Faloye & Ajayi 2022).

Further major barriers to accessing online information are literacy and English proficiency, which could exclude people with low educational attainments, visual impairment, or print disabilities, as well as speakers of the other ten official languages of South Africa who were not fluent in English. Again, this would have most affected rural populations, which tend to be poorer and subject to multiple forms of exclusion (StatsSA 2022).

Municipalities were also assigned responsibilities in local dissemination of information [Supplementary File 1, item 2.1.3], but no detail was given to ensure people with disabilities and other marginalised groups were reached.

2. Implement protective measures against COVID-19

Access to adequate water and sanitation (WASH) was a recognised barrier to infection prevention and control (IPC) measures in many underserved communities [Supplementary File 1, item 6.1.1]. We found two documents addressing this issue. The first dealt with the responsibility of municipalities to provide communities with the means to prevent the spread of COVID-19, including drinking water and adequate sanitation [Supplementary File 1, item 2.1.3]. The other established the National Disaster Water Command Centre, centralising the coordination of WASH rollout for communities deemed to have inadequate access [Supplementary File 1, item 6.1.1]. No mention is made in either document of specific subgroups within target communities that might be prioritised, nor of ensuring services are accessible to people with disabilities.

Provision of personal protective equipment (PPE) and hygiene supplies was included in directions for schools, workplaces, health facilities and other institutional settings [Supplementary File 1, item 3.1.3], but we found no documented intention from any government department to supply these for personal use. Instructions for institutions made no mention of the specific needs of people with disabilities. The DOH’s Draft Manual for the Implementation of the IPC Strategic Framework [Supplementary File 1, item 1.2.1] gives detailed instructions for health facilities, but the only disability considerations concern the safe placement of sanitiser dispensers (with reference to vulnerable populations such as children and mental healthcare users), and the provision of at least one accessible toilet for patients.

Measures to protect specific vulnerable groups from COVID-19 infection focused on those considered at high risk for severe COVID-19 disease, based on emerging clinical evidence. Regulations from the DEL defined vulnerable employees as “employees with known or disclosed health issues or comorbidities, or with any condition which or may place such employees at a higher risk of complications or death than other employees if they are infected with COVID-19” [Supplementary File 1, item 3.1.6:5]; or “employees above the age of 60 years who are at a higher risk of complications or death if infected with COVID-19” [Supplementary File 1, item 3.1.6:5]. The DOH produced concomitant guidelines for managing vulnerable employees [Supplementary File 1, item 1.2.4], which provided for detailed employee risk assessment and adaptation to job roles and requirements where possible. Provisions were also made for paid incapacity leave where risk reduction was not possible. Interestingly, these guidelines expanded the definition of vulnerable employee to include those who “reside with or care for persons that are at high-risk for severe illness from COVID-19 (including family members, aged parents etc.)” [Supplementary File 1, item 1.2.4:1]. This could have provided secondary protection for people with disabilities whose family members are formally employed, but was not found in any other document.

Another group for whom specific protective measures were created was people living in residential care, including old age homes and facilities for people with disabilities. The measures included banning of all visits and in-person family interaction, and a temporary embargo on releasing or discharging residents into the community [Supplementary File 1, item 4.1.2]. Directions for applying IPC measures and handling suspected cases of COVID-19 in mental health institutions were also included in a Department of Health guideline on provision of mental healthcare services during the pandemic [Supplementary File 1, item 1.2.6].

The most specific protection measures for people with disabilities were the arrangements for disability grants and old-age pensions to be collected on a separate day from other social grants (e.g. child support grants) [Supplementary File 1, item 4.2.1]. Disability grants are means-tested income support payments for people unable to work due to a disability, and not receiving any other income. In 2020, the grant was approximately US$106 per month, which even pre-pandemic was inadequate to meet the costs of living with a disability in South Africa (Hanass-Hancock et al. 2017). Grant pay-points are typically crowded, and the risk of infection therefore high. Public transport regulations were also relaxed on those days to allow collection [Supplementary File 1, item 8.3.1].

3. Ensure access to services

We found no evidence of attempts to make testing and treatment services for COVID-19 accessible to people with disabilities. Existing DOH policy does not enforce universal design or access considerations in health facilities, and pre-existing barriers in the built environment would have been compounded by COVID-related restrictions on accompanying family members or personal assistants. Further, many disability-specific services, including rehabilitation, assistive technology, and sign language interpretation, were cancelled as non-essential during the pandemic (McKinney 2021; van Biljon & van Niekerk 2022). This meant that many people with disabilities lost the supports they needed to function and to access services over this time.

Transport poses a major barrier to accessing healthcare for many people with disabilities, as the vast majority of public transport in South Africa is not accessible, and the hire of private transport can be prohibitively expensive. During lockdown, public transport was restricted in hours of operation and loading capacity (down to 50% occupancy during the initial lockdown [Supplementary File 1, item 8.1.1., see also items 8.1.4. and 8.1.5]), which made it less likely that transport drivers would make the extra time and effort to assist a person with a disability (McKinney et al. 2022). No specific transport provisions were made for people with disabilities during this period, except for increasing permitted hours of travel on the days when grants were to be collected [Supplementary File 1, item 8.3.1].

Basic primary healthcare services are free at clinic level for all public healthcare users and charged on a means-tested sliding scale at higher levels of care. People who receive disability grants are entitled to free healthcare at hospitals as well (DSD 2016). This meant that in theory, access to COVID-19 testing and treatment was available to many at low or no cost, but in practice, public sector services were over-subscribed and difficult to access. Private sector services offered better availability and quality of services, but were unaffordable for the majority of the population without medical insurance. For the minority of the population who were insured, COVID-19 was declared a Prescribed Minimum Benefit condition, obliging all insurance schemes to cover COVID-related testing, treatment, and rehabilitation [Supplementary File 1, item 1.1.3], thus reducing financial barriers to healthcare.

The DOH made no specific provisions to ensure access to COVID-related services for people with disabilities. However, the DSD included the following in its first set of directions:

“There must be universal access for Persons with Disabilities in a prescribed manner, to all service points, infrastructure and any other essential service and products that are related to COVID-19.” [Supplementary File 1, item 4.1.2:5]

We found no further documentation of the “prescribed manner”, nor specifics of what facilities were to be rendered accessible or who was responsible. These regulations further stated:

“Persons with Disabilities must have access to personal assistance at all service points, hospitals, screening, testing facilities, supermarkets and any other available facilities which are appropriate” [Supplementary File 1, item 4.1.2:6]

Again, there was no detail provided on how this was to be done, nor (crucially) who would be responsible for providing personal assistance at the various facilities named. These statements from DSD were not found to be translated into directions or guidelines from any other departments.

4. Non-discrimination in medical resource allocation

Three key issues in medical resource allocation arose during the period under study, namely, access to COVID-19 testing, allocation of scarce intensive care unit (ICU) resources, and planning for vaccine rollout.

By mid-2020, the demand for COVID testing overwhelmed capacity. The MAC was asked to produce a strategy to prioritise use of available tests, which identified high- and medium-priority groups for testing. The high-priority group included hospital inpatients and staff, while the medium-priority group included other essential workers, isolation facilities, and care home residents and staff [Supplementary File 1, item 1.2.12]. People with disabilities were not included, other than those residing in care homes.

The allocation of critical care resources (including ICU beds, ventilators, and high-flow nasal oxygen) was not mentioned in any of the documents we identified in our main search. A national guideline produced by the Critical Care Society of Southern Africa [Supplementary File 1, item 1.4.4] was the main reference document in use around the country, although some provinces produced their own policies, largely based on the same principles.

Controversially, the guideline’s decision-making algorithm included use of the Clinical Frailty Scale (CFS) to identify patients most likely to benefit from treatment. The CFS was developed for use with elderly patients, and scores individuals on their physical activity and functional independence prior to admission (Rockwood et al. 2005). Used with the general population, the tool disadvantages people with disabilities, who may be scored as frail for functional reasons, and yet be no less likely to benefit from intervention than able-bodied individuals (McKinney, Swartz, & McKinney 2020). This guideline was amended in May 2020 to state that patients with long-standing but stable disabilities should not be classified using the CFS, but rather assessed individually for medical frailty [Supplementary File 1, item 1.4.4].

In practice, during peak infection periods the demand for critical care far outstripped availability, and many patients who were eligible according to the guideline could not be given care. According to ICU staff in one government hospital, teams had to adapt triage methods continually to cope with this harsh reality (D. Bishop, email, 09/06/2023).

Vaccines were not yet available during 2020; however, the MAC was requested to propose a strategy for when these became available [Supplementary File 1, item 1.2.27]. The suggested allocation framework prioritised “persons with co-morbidities and at risk for morbidity and mortality” [Supplementary File 1, item 1.2.27: Annexure A], which included people over 60 and those living with various medical conditions, as well as “persons in congregate or overcrowded settings” [ibid] such as prisons and care homes. Health workers and essential workers (which could include carers in institutions and schools accommodating people with disabilities) were also given priority. These groupings are similar to those in the testing strategy described above, with the familiar emphasis on age and comorbidity. People with disabilities as such were not mentioned.¹

5. Make mental health interventions inclusive of persons with disabilities

The DOH produced a guideline on mental health interventions during the pandemic in March 2020, an early acknowledgment of the mental health challenges likely to ensue from the situation [Supplementary File 1, item 1.2.6.]. The guideline emphasises mental healthcare as an essential service and focuses on its continuation during lockdown. Alongside usual primary mental healthcare services, providers are instructed to offer “basic practical and emotional support to affected individuals, staff and families” [Supplementary File 1, item 1.2.6:7]. District specialist mental health teams are expected to provide mental health support to primary healthcare workers.

The guideline offers little detail on how mental health services should respond to pandemic conditions, and none at all on making services accessible to vulnerable groups. We found no further documents from the DOH relating to mental health service provision. The DSD made mention of mental healthcare in their initial regulations [Supplementary File 1, item 4.1.2] which state:

“(i) Psychosocial Support Services must be provided to all those infected with or affected by COVID-19;

(ii) Persons with disabilities requiring psychosocial interventions must have access to all prescribed medications and counselling as a minimum requirement for crisis interventions” [Supplementary File 1, item 4.1.2:8]

Once again, these instructions are vague and do not specify who should provide the services stipulated, or how they should be made accessible. The DOH is the primary provider of mental health services (including “prescribed medications”), making this another extra-departmental direction. However, according to a speech by the Minister of Social Development in April 2020, DSD itself deployed 276 psychosocial support teams around the country to provide trauma counselling to people affected by COVID-19, as well as substance abuse treatment at homeless shelters [Supplementary File 1, item 4.2.1].

6. Continuation of support services

The initial period of lockdown confined everyone to their homes, except for purposes of procuring or providing essential goods and services. The definition of essential services was pivotal to the continuation of support services for people with disabilities. Regulations defined essential services as including “medical, health (including mental health), laboratory and medical services” [Supplementary File 1, item 2.1.4:10] and “care services, social relief of distress provided to older persons, mentally ill, persons with disabilities, the sick and children” [2.1.4:10]. People were also permitted to travel to collect grants or seek “lifesaving, emergency or chronic medical attention” [Supplementary File 1, item 2.1.4:6]. These definitions would seem to protect the continuation of personal care and access to healthcare, rehabilitation, and assistive technology services for people with disabilities, but the practicalities were more complicated. Providers of essential services, including caregivers of people with disabilities or people living with mental illness, had to carry a permit indicating their right to travel, which had to be completed by the head of their institution (with the organisation’s stamp). This entirely excluded informal caregivers (e.g. family members) and those who were privately contracted and not part of a care organisation, even though these categories account for the vast majority of caregiving received by people with disabilities in the country (McKinney 2021).

Care arrangements for many people with disabilities were severely disrupted by COVID-19, not only by lockdown but also by the illness itself, as family members fell ill or needed to isolate (Ned et al. 2021). Caregiving services were mentioned in two DSD documents. Firstly, the direction concerning access to personal assistance [Supplementary File 1, item 4.1.2.] was followed by a statement that “where it is deemed necessary, [people with disabilities] may be provided with regular caregiving services at their places of residence” [Supplementary File 1, item 4.1.2:6]. Secondly, instructions for care homes and other institutions included a requirement that centres usually offering community services must have caregivers “available to provide the required home-based care services during the lockdown” [Supplementary File 1, item 4.1.2:7]. No detail was provided on what care might be deemed necessary, nor how this was to be organised or resourced. Existing government services do not cover personal care for people with disabilities, except indirectly where DSD may provide funding to NGO’s (including many of the centres referred to in the direction). Very little service infrastructure therefore existed to carry out this instruction.

A further mention of caregiving arose in a MAC advisory regarding community uptake issues in the COVID-19 response [Supplementary File 1, item 1.2.23]. Among other concerns, many people were refusing to isolate following exposure or infection, because of their care responsibilities for children, older adults, or family members with disabilities. The advisory suggested community mobilisation and networking with community-based organisations to seek local solutions to the problem, but no further evidence of policy intervention in this regard was found.

While “chronic medical attention” was allowed as a reason for travel, many health facilities cancelled all non-emergency outpatient services, including rehabilitation and assistive technology services (Ned et al. 2021). Even where services continued, public transport and movement restrictions, financial constraints, and fears of infection kept people from accessing needed services (McKinney 2021). A MAC advisory on non-COVID health service utilisation documented significantly reduced uptake of key services (including TB, HIV, and immunisations), as well as widespread problems accessing chronic medications [Supplementary File 1, item 1.2.11].

More effective attention was paid to the continuation of access to social grants, including the disability grant. Grant payment services (which include the South Africa Social Security Agency [SASSA], the Post Office, and a network of pay-point partners such as banks and supermarkets) were classified as essential services from the start of lockdown and maintained as such [Supplementary File 1, item 2.1.4]. As mentioned above, separate pay-out days were designated to protect elderly people and people with disabilities. Temporary disability grants, usually approved for six months at a time, were automatically extended during lockdown [Supplementary File 1, items 4.1.1, 4.1.6, and 4.1.7]. However, new grant applications were not possible between March and July 2020 due to the closure of all SASSA offices during lockdown. Accessing the necessary medical reports for such applications remained a challenge long afterwards because of pressures on the health system. A media release in July 2020 announced that 465 doctors had been employed by SASSA specifically to conduct grant assessments in order to deal with the backlog, which would have included people who acquired a disability due to COVID-19 infection [Supplementary File 1, item 4.2.3].

The government also extended its social grants programme during 2020 to mitigate some of the economic effects of lockdown. This included temporarily increasing existing grants with top-up amounts, including an additional R250 per month for disability grant and old age pension recipients (approximately US$14) [Supplementary File 1, item 4.1.4]. While helpful, this was only implemented from May 2020–two months into the pandemic–and was inadequate to counter the additional costs and financial pressures experienced by people with disabilities and their households over this time. Economic relief for the general population included a special COVID-19 Social Relief of Distress payment for unemployed adults, but this excluded existing grant recipients [Supplementary File 1, item 4.3.2].

7. Reasonable accommodations

Lockdown regulations by COGTA [Supplementary File 1, item 2.1.7] explained the types of directions Cabinet members could issue within their line functions. These included instructions relating to lockdown, action to protect people from COVID-19 infection, and “[providing] reasonable measures for persons with disabilities” [Supplementary File 1, item 2.1.7:5].

However, apart from the broad statements by DSD discussed above, we found very few references to reasonable accommodations for people with disabilities in any of the regulations, directions, or guidelines.

Guidelines for quarantine and isolation were published by DOH, including specifications for quarantine facilities [Supplementary File 1, item 1.2.5]. Listed requirements included “disability access” [1.2.5:9]. The only detail on what this meant appeared as a single item in the facility checklist (Annexure 2), namely, “Lift/disability access [Yes/no]” [Supplementary File 1, item 1.2.5:33]. There was a further reference under considerations for room allocations [Supplementary File 1, item 1.2.5:13] that listed elderly persons and persons with disabilities among those to be prioritised (no further detail provided).

Despite detailed procedures on the running of quarantine and isolation facilities, none considered people who might need additional assistance or the presence of a caregiver. This was similarly an issue for people with disabilities admitted in hospital, where visitors were banned during lockdown. Where hospitals are understaffed and staff may lack skills or capacity to provide disability-specific care, relatives may play an essential role in feeding, assisting, and facilitating communication for many people with disabilities. Excluding visitors therefore had a serious impact on people with disabilities needing inpatient care at this time, especially as staff pressures were even greater under COVID-19.

A rare example of personal assistance being accounted for was found in the regulations on medical evacuation procedures. The initial document [Supplementary File 1, item 1.1.6] stated that no accompanying relative or caregiver would be allowed except for minors, where one parent was permitted to travel with him/her. However, this was later amended to allow a person with a disability to be accompanied by one responsible adult [Supplementary File 1, item 1.1.7].

Official regulations on IPC in public places, including mask wearing, did not mention accommodations for people with disabilities. A MAC advisory on masks for children suggested that those unable to tolerate or manage mask-wearing due to their developmental stage or a disability or medical condition should be exempted [Supplementary File 1, item 1.2.22]. A later advisory on mask-wearing in public places recommended that people with disabilities who found mask-wearing impracticable due to their disability should be allowed not to do so [Supplementary File 1, item 1.2.25]. However, this was only produced in December 2020, and we did not find the recommendation reflected in government directions or regulations. To access such accommodations, people with disabilities may have been required to obtain a medical report, which was extremely difficult under pandemic conditions (Huisman 2020).

Specific areas where reasonable accommodations would have been meaningful included movement restrictions and access to transport (including for caregivers), as well as facilitated access to health and support services. Unfortunately, no evidence of action in these areas was found.

8. Consideration of the needs of disabled people who face multiple exclusions

The DSD created temporary shelters for homeless people during lockdown and issued directions for psychosocial support services to be provided to this population [Supplementary File 1, item 4.1.4]. While many homeless people are people living with mental illness and disabilities, this was not specifically mentioned.

Gender-based violence (GBV), already endemic in South Africa, reached new levels during lockdown (McKinney 2021). The existing GBV Command Centre (GBVCC) functioned to support victims of abuse during the pandemic and reported dramatic increases in number of calls received [Supplementary File 1, item 10.1.1]. Access to the GBVCC included a toll-free number, call-back facility, a Skype line for persons with hearing impairments, and an SMS-based line for persons with disabilities [Supplementary File 1, item 4.3.3].

9. Protection of people living in residential settings

The original lockdown regulations [Supplementary File 1, item 2.1.2] suspended all visitors to health and social care institutions. Schools and partial care facilities were closed, which meant that learners with disabilities living in hostels were sent home at very short notice, whether or not families were able to receive them.

DSD regulations initially stopped all releases from institutions for the duration of lockdown [Supplementary File 1, item 4.1.2]. This was then amended [Supplementary File 1, item 4.1.4] to allow releases on the recommendation of a social worker, and further stipulated that in the case of a person with a disability, the social worker must “be satisfied with the state of readiness” [Supplementary File 1, item 4.1.4:4] of the place that would accommodate the person being released. Such recommendations for release were to consider “disability needs for persons with severe disability” [Supplementary File 1, item 4.1.4:5], but no further definition or specification was provided in this regard.

Residential and respite facilities (including substance abuse treatment centres, old age homes, and halfway houses) had similar restrictions on visitors, admissions, and releases [Supplementary File 1, items 4.1.2 and 4.1.4].