MENA Disability Report 11 - 30 - 03.01.2023

Children with Disabilities in
the Middle East and North Africa:

A statistical overview of their well-being
© United Nations Children’s Fund (UNICEF), Division of Data, Analytics, Planning and
Monitoring, October 2022
Permission is required to reproduce any part of this publication. Permission will be

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Suggested citation: United Nations Children’s Fund, Children with Disabilities in the
Middle East and North Africa: A statistical overview of their well-being, UNICEF, New
York, 2022.
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Acknowledgements
The preparation of this publication was led by Claudia Cappa (Data and Analytics
Section, UNICEF Headquarters) with support from Claire Thomson (independent
consultant). Munkhbadar Jugder contributed to data processing (Data and Analytics
Section, UNICEF Headquarters). Prashant Ranjan Verma (independent consultant)
assisted with accessibility features. The report was edited by Lois Jensen and
designed by Era Porth (independent consultants). Valuable feedback and inputs
were provided by Rockaya Aidara, Bertrand Bainvel, Shirin Kiani, Adele Khodr and
Leonardo Menchini (UNICEF Regional Office for the Middle East and North Africa),
Anthony MacDonald (UNICEF Qatar), and Tyler Andrew Porth and Jennifer Requejo
(Data and Analytics Section, UNICEF Headquarters). The report includes content
from UNICEF’s global report, Seen, Counted, Included: Using data to shed light on
the well-being of children with disabilities, which was prepared with inputs from
several additional experts. For a complete list of contributors, please consult that
publication.
This report was made possible through core funding to UNICEF and a generous
grant from the Department of Foreign Affairs and Trade of the Government of
Australia. It was prepared for the 2022 World Innovation Summit for Health (WISH).
© UNICEF/UN0276053/Herwig
Contents
5 Foreword 6 Introduction 12 Every child has the 20 Every child has the 26 Every child has the
right to be counted right to survive and right to a nurturing
thrive family environment,
free from violence
32 Every child has the 38 Every child has the 42 Fulfilling the rights 46 Technical annex
right to learn right to a happy of every child in the
life, free from Middle East and 52 Endnotes
discrimination North Africa
4 Children with Disabilities in the Middle East and North Africa: A statistical overview of their well-being
© UNICEF/UN0374251/
5
Foreword
The Middle East and North Africa is home to nearly 21 million children with availability of data on children with disabilities, prompted new analyses and
disabilities. In other words, one in seven children in the region has one yielded greater knowledge. These tools employ a comprehensive definition
or more functional difficulties. Disability is not always visible and is often of disability based on functional difficulties versus medical diagnoses. They
overlooked. look at disability as a continuum, and include those impairments that may not
be visible or readily apparent but that affect a child’s ability to function in daily
Most children with disabilities in the region are isolated and excluded from life. This information can help governments craft appropriate and carefully
society and their communities. They are often unable to learn, socialize, play targeted programmes.
and enjoy leisure activities. Their right to proper care, adequate nutrition
and quality health services, and education, along with social protection, are Late last year, UNICEF published Seen, Counted, Included: Using data to
frequently denied or deemed a low priority. This is occurring despite national shed light on the well-being of children with disabilities. It presented the
commitments to support these children, the nearly universal ratification by first global and regional estimates on children with disabilities and their well-
countries in the region of both the Convention on the Rights of the Child being in multiple dimensions. This current report is a by-product of that global
and the Convention on the Rights of Persons with Disabilities, as well as analysis and reflects data generated in the Middle East and North Africa. It
endorsement of the 2030 Agenda for Sustainable Development and its focuses on four countries (Algeria, Iraq, State of Palestine and Tunisia) that
pledge to leave no one behind. have conducted a MICS in recent years. It provides decision-makers with
crucial evidence for policy and programming to give every child – especially
For many years, the lack of reliable data and analysis has contributed to an those with disabilities – an equal chance in life.
underestimation of the number of children with disabilities needing services,
often leading to extreme exclusion and neglect. Such rights violations and Join us in the journey to make this change happen!
marginalization follow children into adolescence and lead many to a life of
dependency and poverty.
Adele Khodr
It does not have to be this way. New data collection tools – which have been Regional Director
included in household survey programmes such as the Multiple Indicator UNICEF Regional Office for the Middle East and North Africa
Cluster Surveys (MICS) and censuses – have increased significantly the
Introduction
Nearly 21 million children with disabilities live in the Middle East and North Africa. Each of them – like every child
in the world – has the right to be nurtured and supported through responsive care and education, to receive
adequate nutrition and social protection, and to enjoy play and leisure time. Too often, however, such rights
are denied. The reasons vary. They include stigma, lack of accessible services, institutionalization and physical
barriers, but the consequences are sadly consistent. When marginalized from society, these children’s chances
to survive and thrive are diminished, along with their prospects for a bright future.
In 2015, the adoption of the 2030 Agenda for Sustainable Development was framed around the pledge of
leaving no one behind. It calls for a commitment to ensure that all 17 Sustainable Development Goals (SDGs),
comprising 169 targets, are achieved for the benefit of all members of society. It emphasizes reaching those
furthest behind first, which inevitably includes children with disabilities and their families.
Monitoring the inclusion of children with disabilities in development efforts has long been held back by the lack
of reliable and comprehensive data. Recent years, however, have seen renewed efforts to fill these data gaps.
The development of new data collection tools has resulted in a substantial increase in the availability and quality
of data on children with disabilities, fostering new analyses and contributing to increased knowledge generation.
This report is a testament to these efforts. It includes internationally comparable data from four countries in the
Middle East and North Africa and covers 18 indicators of child well-being – from nutrition, health and education
to protection from violence, exploitation and discrimination. It also presents global and regional estimates of
children with disabilities drawn from more than 1,000 data sources, including 95 from countries in the Middle
East and North Africa.
The report’s objective is to promote the use of these data to make children with disabilities in the region more
visible, bringing about a fuller understanding of their life experiences. It offers evidence crucial to decision-
making to fulfil obligations, both moral and legal, to give every child an equal chance in life.
INTRODUCTION 7
© UNICEF/UN0217181/Shennawi
Understanding disability in children a failure of the policy, cultural and physical environments to accommodate
differences in function. For instance, children with myopia who do not have
Children with disabilities are a highly diverse population group. They include access to diagnostic services and glasses will have difficulty seeing, whereas
children who were born with a genetic condition that affects their physical, those who have such access will not. Furthermore, children with similar
mental or social development; who sustained a serious injury, nutritional functional difficulties may participate in society to varying degrees because
deficiency or infection that contributed to long-term functional difficulties; or of physical, communication and cultural barriers. Access to assistive devices,
who were exposed to environmental toxins that resulted in developmental technology and services, as well as exposure to nurturing relationships and
delays. Children with disabilities also include those who developed anxiety or positive social norms and beliefs, are crucial to promoting the inclusion of all
depression as a result of stressful life events. children, regardless of their impairments.
Disability is a complex and evolving concept, involving aspects of body Counting children with disabilities
function and structure (impairments), capacity (measured by the ability to
carry out basic activities without the benefit of assistance in any form), and The availability of data on children with disabilities has been a longstanding
performance (measured by the individual’s ability to carry out these same challenge due to limitations related to the use of narrow definitions and the
basic activities using assistance). As stated in the Convention on the Rights lack of a standardized data collection methodology. While most countries
of Persons with Disabilities, disability stems from the interaction between have produced estimates of the number of persons with disabilities, the
certain conditions or impairments and an unaccommodating environment use of different measurement tools limits the validity and comparability
that hinders an individual’s full and effective participation in society on an of data. The definition of disability that is used in any given data collection
equal basis with others. The framework of the International Classification instrument determines who is identified as having a disability and included
of Functioning, Disability and Health (ICF) relies on a three-level model to in the appraisal of evidence. Different conceptualizations and differences in
describe the concept of disability. According to the ICF, disability can occur as: operationalizing the concept of disability will directly impact the quality and
utility of the gathered data. Historically, measures of disability have focused
• An impairment in body function or structure (for example, a cataract or on domains related to physical and sensory functioning, while other domains,
opacity of the natural lens of the eye, which prevents the passage of rays notably those related to psychosocial functioning, were largely overlooked.
of light and impairs or destroys sight) Language that was stigmatizing or judgemental was also commonly found in
• A limitation in activity (for example, low vision or inability to see, read or some of the questionnaires used to determine disability status.
engage in other activities)
• A restriction in participation (for example, exclusion from school or An additional limitation to the production of high-quality data on children with
participation in other social, recreational or other events or roles). disabilities relates to the protocols used to collect them. Non-inclusive data
collection methods and analyses can lead to the generation of inaccurate,
The ICF framework defines disability within a biopsychosocial model, incomplete, irrelevant or misleading evidence.1 The absence of inclusiveness
integrating both factors pertaining to the individual and his or her environment. may result in severe underestimations and misidentification of persons with
In contrast, the medical model defines disability as a problem resulting from disabilities, aggravating exclusion and preventing the implementation of efforts
a medical condition. Awareness of the important role of the social context in where they are most needed. Further to the considerations on measuring
defining disability led to the development of the social model of disability, which disability in general, identifying children with disabilities presents additional
defines disability not merely as a medical condition or diagnosis but rather as challenges. The domains of functioning that may indicate that a young child has
INTRODUCTION 9
a disability are different from those in older children and adults. For example, those in the Child Functioning Module, serve as a better basis for identifying
asking about difficulties related to self-care is relevant among older children children with disabilities. For the purposes of social participation and equalizing
and adults but not young children. In addition, measuring functional difficulties opportunities, functional status – and how that impacts someone’s life – is of
is complex since children, especially at younger ages, develop at different greater interest than the cause (medical or otherwise) since children with
rates. Therefore, the identification of functional difficulties in children needs to the same conditions or impairments may have very different degrees of
account for what is a typical variation in development versus a developmental difficulties. For example, one child with cerebral palsy might have a slight
delay or a consequence of a specific impairment. Measuring disability among speech impairment but can easily be understood while another child with
children requires instruments that are specifically designed to reflect the the same condition might not be able to speak at all, making communication
breadth of functional domains that are relevant for children. During childhood, challenging. Some of these difficulties are traditionally seen as a ‘disability’
this implies accounting for all the domains of physical, psychosocial, sensory while others are not. The Child Functioning Module is comprised of two
and cognitive functioning. Furthermore, a comprehensive measure of disability questionnaires, one with 16 questions for children aged 2 to 4 years and another
must include all sorts of individual and environmental factors that may prevent with 24 questions for children aged 5 to 17 years. The questions are to be
children from developing skills and building trustworthy relationships and that administered to the mother or primary caregiver of the child in question. They
inhibit their full and effective participation in society on an equal basis with are designed to identify difficulties according to a range of severity. To better
others. reflect the degree of functional difficulty, each area is assessed against a rating
scale. In addition to collecting data on domains related to physical, sensory
A new way to identify children with disabilities in data and cognitive functioning, the Child Functioning Module includes questions
collection efforts on difficulties in psychosocial functioning. These questions identify children
having difficulties expressing and managing emotions, accepting changes,
To address the paucity of data on the situation of children with disabilities controlling behaviour and making friends. While all children may sometimes
globally, UNICEF and the Washington Group on Disability Statistics developed manifest worry, sadness or anxiety, these emotions may be significant and
the Child Functioning Module for use in censuses and surveys. The module is frequent enough to place certain children at higher risk of dropping out of
intended to provide a population-level estimate of the number and proportion school, withdrawing from family or community life, or harming themselves.
of children with functional difficulties. The module covers children between 2 The reporting of anxiety or depression should be interpreted as an indication
and 17 years of age and assesses difficulties in various domains of functioning.2 of those conditions, rather than as a clinical diagnosis. Results should not
It conforms to the biopsychosocial model of disability, focusing on the be used to assess the epidemiological characteristics of any disease or
presence and extent of functional difficulties rather than on body structure impairment; rather, they provide an indication of the prevalence of moderate
or conditions. For example, a mobility limitation can be the result of cerebral to severe functional difficulties that, in interaction with various barriers, can
palsy, loss of limbs, paralysis, muscular dystrophy or spinal cord injuries. place children at increased risk for non-participation and exclusion.
Behavioural issues may result from autism, attention deficit hyperactivity
disorder or a mental health condition. Basing disability statistics on questions While the Child Functioning Module was originally developed and tested
that ask about diagnosable conditions is problematic. Many caregivers may for use with surveys and censuses, work is ongoing to test the use of the
not know their child’s diagnosis, particularly if this involves mental and module with other data sources, including administrative records. These
psychosocial conditions; and knowledge about diagnoses is often correlated efforts include testing the questions in education and health management
with education, socioeconomic status and access to health services, all of information systems.
which may bias collected data. Questions that focus on basic actions, such as
The Child Functioning Module was developed in consultation with organiza- the fact that this six-question module was designed to produce internationally
tions of persons with disabilities, among other stakeholder groups. comparable data on adults with disabilities.6 It therefore underestimates
the proportion of children with disabilities (see Technical annex) and is not
These organizations were instrumental in the design of the module, including recommended for collecting data on this population group. Seventy-six sources
through their engagement during its validation in the field.3 The module also of data were generated using a variety of instruments, which relied on diverse
underwent extensive review by other experts and was tested in several definitions, had different numbers of questions and used different wording for
countries to determine the quality of questions and how well they are those questions (Table1). The use of non-standard tools is problematic, since
understood by people in diverse cultures.4 In March 2017, a joint statement different methodologies and approaches can produce significantly different
issued by multiple UN agencies and Member States, organizations of persons estimates of children with disabilities, even within the same country, and
with disabilities and other stakeholders recommended the module as the result in data of varying quality and scope (Figure 1).
appropriate tool for SDG data disaggregation for children.5
Indeed, the proportions of children with disabilities identified through these
The development of the Child Functioning Module and its roll-out as part different data sources across countries in the Middle East and North Africa
of the Multiple Indicator Cluster Survey (MICS) programme has led to the varied widely, with estimates ranging from 0.1 per cent among children aged
release, for the first time, of cross-nationally comparable data on children 0 to 14 years in Egypt (Census 1976), to 29 per cent among children aged 2 to
with disabilities. In addition, many countries have also included the module as 9 years in Yemen (MICS 2006).
part of their nationally representative surveys. Estimates from more than 50
countries have been released as of September 2022, and data from at least 10 That said, it is worth noting that most of the population-level data collection
more surveys are expected to become available over the next couple of years. in this region over the last decade has relied on tools such as the Child
Functioning Module and Washington Group Short Set on Functioning, which
The availability of data on children with disabilities in the produce internationally comparable data. This trend is a positive step towards
Middle East and North Africa strengthening the availability and quality of data on children with disabilities in
the region. As data collection efforts continue and expand across the Middle
The limitations affecting the availability, quality and comparability of data on East and North Africa, countries should continue to prioritize the collection of
children with disabilities worldwide are also found in the Middle East and data on children with disabilities using the Child Functioning Module. In doing
North Africa. so, they can help ensure that the right of all children to be seen, counted and
included is fulfilled.
All countries in this region have collected some data on children with disabilities,
and most have more than one data source, indicating that data have been TABLE 1 Number of data sources on children with disabilities in the Middle East
gathered at repeated intervals. Over the last six decades, at least 95 sources and North Africa, by tool used to identify such children
generated population-level data on children with disabilities (51 censuses and
44 surveys). The oldest source of data is from 1964 and the most recent from Number of data sources
2020. Of these 95 data sources, five were based on the Child Functioning The Child Functioning Module 5
Module; of these five, four used the Child Functioning Module as part of a
Washington Group Short Set 14
MICS conducted between 2018 and 2020. Fourteen sources collected data
Other tools 76
on children using the Washington Group Short Set on Functioning, despite
INTRODUCTION 11
BOX 1 Collecting data on children with disabilities through Multiple Indicator Cluster Surveys
The MICS programme is designed to assist countries in collecting and analysing The questionnaires are all modular in nature and can be adapted or customized
data on the situation of women and children. Since its inception in the mid-1990s, to the needs of the country. Trained fieldwork teams conduct interviews with
the MICS has enabled nearly 120 countries to collect nationally representative and household members on a variety of topics – focusing mainly on those issues that
internationally comparable data on more than 100 key indicators in areas such as directly affect the lives of children and women. The MICS is an integral part of
nutrition, child health, mortality, education, water and sanitation, child protection, the policies and plans of many governments around the world and a major data
and HIV and AIDS. source for more than 30 SDG indicators.
The MICS tools, including core questionnaires and modules on specific topics, Starting in 2016, the Child Functioning Module and the Washington Group Short
are developed by UNICEF in consultation with relevant experts from various UN Set on Functioning became part of the MICS and are used to collect data on
organizations and interagency monitoring groups. The surveys are designed by children aged 2 to 17 years and on adult women and men aged 18 and older,
country teams and implemented by local agencies, typically national statistical respectively. With the inclusion of these two tools, the MICS programme has
offices. The core questionnaires are a household questionnaire, a questionnaire become the largest source of internationally comparable data on children and
for individual girls and women between the ages of 15 and 49, a questionnaire for adults with disabilities. When analysed in conjunction with other MICS indicators,
individual boys and men aged 15 years and older, a questionnaire on children under the data can be used to document the inequities experienced by persons with
age 5 (administered to mothers or primary caregivers), and a questionnaire on disabilities at the global level.
children aged 5 to 17 years (also administered to mothers or primary caregivers).
FIGURE 1 How questionnaire design impacts the percentage of children identified as having disabilities: The example of Tunisia
Census (1984) - Census (1994) - Census (2014) - MICS (2018) -

Children aged 0 to 14 years Children aged 0 to 14 years Children aged 0 to 17 years Children aged 2 to 17 years
0.3 0.6 20
2
Does this person have a disability? If yes, list type: Handicap of upper Does this person have difficulties in Does (child) have difficulties in seeing, hearing, walking, fine motor skills, playing, learning,
limbs; handicap of lower limbs; totally handicapped; blind; mute; deaf; seeing, hearing, mobility, cognition, controlling behaviour, communication, self-care, accepting change, concentrating, remembering,
deaf-mute; developmental delay; mentally retarded; undeclared. self-care, or communication? No making friends? No difficulty, some difficulty, a lot of difficulty, cannot do at all. How much does the
difficulty, some difficulty, a lot of child kick, bite or hit other children or adults? Not at all, the same or less, more, a lot more, How
difficulty, cannot do at all. often does (child) seem anxious or depressed? Daily, weekly, monthly, a few times a year, never.
Every child has the right

to be counted
Data provide the foundation for

understanding who children with
disabilities are and the scope and depth
of the deprivation they face. When put
to use through advocacy and in forging
transformative policies and programmes,
data have the power to change lives.
© UNICEF/UN0603269/Chnkdji
EVERY CHILD HAS THE RIGHT TO BE COUNTED 13
Indicators and data sources used in this chapter These include:
This report aims to generate evidence on children with disabilities aligned, to • Seeing, even if using glasses
the greatest extent possible, with the Convention on the Rights of Persons • Hearing, even if using a hearing aid
with Disabilities and the biopsychosocial model of disability. This intent • Walking, even if using equipment or assistance
guided the production of the global and regional estimates and is reflected in • Understanding or being understood when speaking
country-level data collected by the Child Functioning Module. In line with this • Picking up small objects with their hands
approach, the expression ‘children with disabilities’ used in charts and tables • Learning things
throughout the report refers to ‘children with functional difficulties’. • Playing.
The regional and global estimates presented in Figures 2 and 3 rely on Children aged 5 to 17 years who reportedly seem very anxious, nervous or
information about functional difficulties or limitations among children gathered worried and/or very sad or depressed on a daily basis and/or who have ‘a lot
through more than 100 data sources with some degree of international of difficulty’ or ‘cannot do at all’ certain functions. These include:
comparability. The selection of data sources involved an extensive process
of data compilation and consultations with country-level experts to overcome • Seeing, even if using glasses or contact lenses
limitations on data availability and comparability, and to ensure their views were • Hearing, even if using a hearing aid
reflected in the data selection, harmonization and estimation process. In the • Walking on level ground, even if using equipment or assistance
case of countries in the Middle East and North Africa, the regional estimates • Performing self-care activities, such as feeding or dressing themselves
are based on data from 10 countries that used the Child Functioning Module (5 • Being understood when speaking to people inside or outside their
countries) and the Washington Group Short Set (5 countries). The 10 countries household
are home to 73 per cent of the population of children in this region. In order • Learning things
to use data obtained through different instruments, the estimation process • Remembering things
was based on meta-analyses of proportions that were considered suitable to • Concentrating on an activity they enjoy
account for the variability of the data. Detailed technical information on the • Accepting changes in their routine
estimation work and data sources is provided in the technical annex at the • Controlling their behaviour
end of the report. • Making friends.
The country data presented in this chapter are drawn from MICS conducted in Children with more than one functional difficulty include all children who have
Algeria, Iraq, State of Palestine and Tunisia between 2018 and 2020. Children difficulties functioning in more than one of the domains listed above.
with one or more functional difficulties include the following:
Children aged 2 to 4 years who reportedly kick, bite or hit other children or
adults a lot more than other children of the same age and/or who have ‘a lot
of difficulty’ or ‘cannot do at all’ certain functions.
Thirteen per cent of children in the Middle East and North Africa have disabilities
FIGURE 2 Percentage of children aged 0 to 17 years with disabilities
15
13
World
11 10
10 10 10
Europe and East Asia and North Latin America Eastern and South Asia Middle East and West and
Central Asia the Pacific America and the Southern North Africa Central Africa
Caribbean Africa
Note: The size of the circles reflects the number of children with disabilities in the respective regions.
Of the 240 million children globally with disabilities, 20.9 million live in the Middle East and North Africa
FIGURE 3 Number of children aged 0 to 17 years with disabilities
South Asia West and Central Africa Eastern and

64.4 million 41.1 million Southern Africa
28.9 million
Middle East and Latin America and Europe and

East Asia and the Pacific North Africa the Caribbean Central Asia
43.1 million 20.9 million 19.1 million 10.8 million
North America
8.0 million
Notes: The global estimate is based on a subset of 103 countries and areas covering 84 per cent of the global population of children aged 0 to 17 years. Regional estimates represent data covering at least 50 per cent of the regional population of children.
The proportion of children with disabilities varies significantly across countries and is highest in Tunisia, for children of all ages
FIGURE 4 Percentage of children aged 2 to 4 years with one or more functional difficulties
4 3 3 2
Tunisia Iraq Algeria State of Palestine
24 22 21 15
20 19 17 12

In most countries, a significantly higher proportion of boys than girls have functional difficulties
Boys Girls
21 18 21 16 19 14 15 10
Note: Differences for Tunisia are not statistically significant.
Children from the poorest households have a higher proportion of functional difficulties than their richest counterparts
Poorest 20% Richest 20%
24 14 21 13 18 14 14 11
Note: Differences for the State of Palestine are not statistically significant.
Most children with disabilities have functional difficulties in only one domain
Children with difficulty in one domain Children with difficulty in two or more domains
0.9
0.8 1 0.7
3 2 2 2
Tunisia Algeria Iraq State of Palestine
Note: Some of the values presented in this chart do not match those in Figure 4 due to rounding.
Children with difficulty in one domain Children with difficulty in two or more domains
8
7
7
16 15 14 10

The proportion of children with functional difficulties varies significantly by domain; however, psychosocial difficulties predominate across all countries
TABLE 2 Percentage of children aged 2 to 17 years with one or more functional difficulties
Algeria Iraq State of Palestine Tunisia

Seeing 0.9 0.7 0.6 0.9
Hearing 0.4 0.3 0.4 0.3
Walking 1 2 1 1
2 to 17 years
Communicating 1 0.9 0.6 0.9
Learning 1 1 1 1
Controlling behaviour 2 1 2 3
Fine motor skills 0.3 0.4 0.4 0.4
2 to 4 years
Playing 0.5 0.7 0.4 0.6
Self-care 0.8 0.9 0.5 0.9
Remembering 1 1 0.9 1
Concentrating 1 0.8 0.6 2
5 to 17 years Accepting change 3 2 1 3
Making friends 1 1 1 2
Signs of anxiety 13 16 10 17
Signs of depression 4 7 2 4
Every child has the right

to survive and thrive
All children have the right to survive and develop,

and to live a life free from disease, illness or other
conditions that affect their well-being and future
prospects.7 Access to adequate nutrition and quality
health care, including immunization, is paramount in
making this right a reality for every child.
© UNICEF/UNI275331/Choufany
EVERY CHILD HAS THE RIGHT TO SURVIVE AND THRIVE 21
Indicators and data sources used in this chapter
The country data presented in this chapter are drawn from MICS conducted in
Algeria, Iraq, State of Palestine and Tunisia between 2018 and 2020.
Prevalence of acute respiratory infection (ARI) symptoms: Percentage of

children aged 24 to 59 months for whom the mother reported symptoms of
ARI in the last two weeks.
Prevalence of diarrhoea: Percentage of children aged 24 to 59 months for

whom the mother reported an episode of diarrhoea in the last two weeks.
Prevalence of fever: Percentage of children aged 24 to 59 months for whom

the mother reported an episode of fever in the last two weeks.
Moderate and severe underweight prevalence: Percentage of children

aged 24 to 59 months who fall below minus two standard deviations of the
median weight-for-age of the World Health Organization (WHO) Child Growth
Standards.
Moderate and severe stunting prevalence: Percentage of children aged 24

to 59 months who fall below minus two standard deviations of the median
height-for-age of the WHO Child Growth Standards.
Definitions and data interpretation issues
Some of the findings in this chapter present limitations. Since the Child
Functioning Module only captures information on children 2 years of age
and older, some health and nutrition outcomes that may affect children with
disabilities before this age are not reflected in the data. This is significant
since before age 2 vulnerability to infection remains high and challenges may
arise in providing early nutrition (such as difficulties in breastfeeding).
Findings on disease symptoms and reported disease episodes also present

limitations. Symptoms of ARI are collected to capture symptoms related to
pneumonia, a leading cause of death in children under the age of 5. In the
data analysed, a child was considered to have had symptoms of ARI if the Children with disabilities are overrepresented in the number of children with
mother reported that the child had, over the specified recall period (that is, missing anthropometric data. The two main reasons for missing data are
two weeks prior to the survey), an illness with a cough and rapid or difficult that the child was not measured or that the data were collected but were
breathing and whose symptoms were perceived to be due to a problem in the implausible within the WHO growth standards reference z-scores. While
chest, or both a problem in the chest and a blocked or runny nose. While this the findings presented in this chapter do not specify the reason for missing
approach is reasonable in the context of a multi-topic household survey, these data, they do provide some insights into the challenges around height and
simple case definitions must be kept in mind when interpreting the results weight measurement of children with disabilities. These include: (1) difficulty
and the potential for reporting and recall biases. Furthermore, diarrhoea, fever measuring a child with an impairment (for example, if limbs are deformed
and ARI can be seasonal and characterized by the rapid spread of localized due to polio and proper use of the measurement equipment is not possible),
disease outbreaks from one area to another at different points in time. The which may mean the measurement was not carried out at all; (2) the quality
timing of the survey and the location of the teams, therefore, might affect of the measurement may be poor due to the child’s inability to stand upright,
the results considerably. Thus, these data must be interpreted with caution leading to inaccuracies; and (3) the growth standard used to generate the
and should not be used to assess the epidemiological characteristics of the z-score for each child may yield an implausible value. This may be due either
underlying diseases; rather, they provide an indication of the prevalence of to the way in which children with certain impairments grow or to errors in
illnesses over a short period of time. Such data are generally used for defining measurement exacerbated by the child’s condition, meaning that these
the population in need of treatment and not as true prevalence measures. children would not be included in the estimates at all. For all these reasons,
Finally, data on ARI symptoms and on episodes of diarrhoea and fever by the results presented may not accurately describe the nutritional status of all
disability status should not be interpreted as reflecting a causal relationship. children with disabilities.
Rather, they may indicate some level of association.
Findings on nutritional status should also be interpreted with caution.

Anthropometric measurements are carried out by trained measurers and
under uniform conditions, which include the use of standardized digital scales
and measurement boards. Nevertheless, collecting data on the growth of
children with disabilities presents additional challenges. Children with certain
types of impairments may not grow in the same way as children who develop
more typically. This may mean that their health and development cannot
be properly measured by standard tools used in the context of household
surveys. Moreover, measuring and weighing children with specific types
of impairments may lead to larger measurement errors. Finally, it should
be noted that the WHO Child Growth Standards were calculated based on
children without physical impairments. Therefore, even when a child’s height
and weight can be collected, standard nutrition indicators (used to measure
underweight and stunting) may be inappropriate to assess growth for certain
© UNICEF/UN0482107/
children with disabilities, making findings more difficult to interpret.
In the State of Palestine and Tunisia, children with disabilities are more than twice as likely to have reported symptoms of ARI than their
peers without disabilities
FIGURE 11 Percentage of children aged 24 to 59 months for whom the mother reported symptoms of acute respiratory infection in the last two weeks
Children without functional difficulties Children with one or more functional difficulties
6 6
3 3 3 4 13 15
Algeria Iraq Tunisia State of Palestine
Note: Differences for Algeria and Iraq are not statistically significant.
In all countries except the State of Palestine, children with disabilities are more likely to have a reported episode of diarrhoea than their
peers without disabilities
FIGURE 12 Percentage of children aged 24 to 59 months for whom the mother reported an episode of diarrhoea in the last two weeks
4 5 12 11 15 16
9 8
Algeria Tunisia State of Palestine Iraq
In Tunisia, children with disabilities are almost twice as likely to have a reported episode of fever than their peers without disabilities
FIGURE 13 Percentage of children aged 24 to 59 months for whom the mother reported an episode of fever in the last two weeks
16 21 16 22 16 24 18 35
Algeria State of Palestine Iraq Tunisia
Note: Differences for Algeria and the State of Palestine are not statistically significant.
In Iraq and Algeria, children with disabilities are over three times more likely to be underweight than children without disabilities
FIGURE 14 Percentage of children aged 24 to 59 months who are underweight
0.9 1 2 2 3
5 7 11
Tunisia State of Palestine Algeria Iraq
Note: Differences for the State of Palestine and Tunisia are not statistically significant.
In Iraq, children with disabilities are also significantly more likely to be stunted
FIGURE 15 Percentage of children aged 24 to 59 months who are stunted
8 9 8 13 10 14 10 18
State of Palestine Tunisia Algeria Iraq
Note: Differences for Algeria, State of Palestine and Tunisia are not statistically significant.
© UNICEF/UN0445936/Karimi
Every child has the right to a nurturing

family environment, free from violence
All children have the right to grow up

in a family environment that provides
them with the love, nutrition, protection
from violence, opportunities for early
learning and responsive care they
require to survive, grow and thrive.8
© UNICEF/UN0403296/Noorani
EVERY CHILD HAS THE RIGHT TO A NURTURING FAMILY ENVIRONMENT, FREE FROM VIOLENCE 27
Indicators and data sources used in this chapter children who are at least 2 years old, children under age 2 are not represented
in the data. The findings, therefore, do not reflect outcomes among younger
The data presented in this chapter are drawn from MICS conducted in Algeria, children, for whom a lack of responsive care or playthings is crucial.
Iraq, State of Palestine and Tunisia between 2018 and 2020.
Findings regarding violent methods of discipline should be interpreted
Early stimulation and responsive care: Percentage of children aged 24 to 59 with caution since, for a significant percentage of children with functional
months who engaged in four or more activities to provide early stimulation difficulties, no disciplinary method was reported. For children with difficulties
and responsive care in the last three days with any adult household member. in some domains of functioning, the finding of ‘no discipline method reported’
Activities include reading books or looking at picture books with the child; is more than five times greater than it is for children without disabilities,
telling stories; singing songs to or with the child; taking the child outside the suggesting issues within this indicator that may have numerous explanations.
home; playing with the child; naming, counting or drawing things for or with Data for this indicator are collected by the interviewer asking whether a child
the child. is subjected to different disciplinary methods – both positive and negative.
It is therefore possible that the methods used on children with disabilities
Availability of children’s books: Percentage of children aged 24 to 59 months vary significantly from those used on children without disabilities. However,
who have three or more children’s books. as these are not mentioned in the survey, they have gone unrecorded.
Alternatively, it could be indicative of parents not engaging with their children
Availability of playthings: Percentage of children aged 24 to 59 months who with disabilities and putting time and energy into disciplining them, either
play with two or more types of playthings. Playthings include homemade positively or negatively.
toys, such as dolls, cars or other toys made at home; toys from a shop or
manufactured toys; household objects, such as bowls or pots; or objects
found outside, such as sticks, rocks, animal shells or leaves.
Severe physical punishment: Percentage of children aged 2 to 14 years who

experienced severe physical punishment by caregivers in the past month.
Attitudes towards physical punishment: Percentage of mothers of children

aged 2 to 14 years who believe physical punishment is needed to bring up,
raise or educate a child properly.
Definitions and data interpretation issues
An overarching limitation that runs through some of the indicators regards

the age of children measured. Early childhood development indicators that
address early stimulation and responsive care, as well as the availability of
children’s books and playthings, all measure responses for children under the
age of 5 years. However, since the Child Functioning Module only covers © UNICEF/UN0445936/Karimi
Children with disabilities are significantly less likely to receive early stimulation and responsive care than children without disabilities
FIGURE 16 Percentage of children aged 24 to 59 months who engaged in four or more activities to provide early stimulation and responsive care in the last three days with any adult
household member
76 57 74 52 62 46 45 35
State of Palestine Tunisia Algeria Iraq
In Tunisia, children with disabilities are significantly less likely to have three or more children’s books than their peers without disabilities
FIGURE 17 Percentage of children aged 24 to 59 months who have three or more children’s books
5 3
37 20 18 9 13 9
Note: Differences for Algeria, Iraq and the State of Palestine are not statistically significant.
Children with disabilities in Algeria and the State of Palestine are less likely to have two or more types of playthings than children without disabilities
FIGURE 18 Percentage of children aged 24 to 59 months who play with two or more types of playthings
85 67 72 67 57 66 58 45
State of Palestine Tunisia Iraq Algeria
In Iraq,Tunisia and Algeria, children with disabilities are more likely to experience severe physical punishment than children without disabilities
FIGURE 19 Percentage of children aged 2 to 14 years who experienced severe physical punishment by caregivers in the past month
17 23 21 24 21 36 30 40
Algeria State of Palestine Tunisia Iraq
In most countries, mothers of children with disabilities are more likely to believe that physical punishment is needed to raise a child properly
FIGURE 20 Percentage of mothers of children aged 2 to 14 years who believe physical punishment is needed to bring up, raise or educate a child properly
19 17 15 18 14 22 19 26
Algeria Iraq State of Palestine Tunisia
© UNICEF/UN0539870/Noman
Every child has

the right to learn
Education provides children with the

knowledge and skills they need to grow
and prosper, creating well-being, pathways
to future opportunities and healthier lives.
Ensuring opportunities for all children
to succeed in school requires equity
and inclusion that guarantees access,
participation, progress and achievement
of key learning outcomes. This means
addressing all aspects of a child’s educational
path and eliminating the disparities and
barriers that begin early in life, accumulate
during childhood and generate further
disadvantages for the most marginalized
children, including children with disabilities.
© UNICEF/UNI277686/El-Dalil
EVERY CHILD HAS THE RIGHT TO LEARN 33
Indicators and data sources used in this chapter they fall short in fully capturing the experiences of children with disabilities in
obtaining an education and the barriers they face. Additional information and
The country data presented in this chapter are drawn from MICS conducted in data sources are needed to gain such understanding.
Algeria, Iraq, State of Palestine and Tunisia between 2018 and 2020.
Another data limitation is the inability to distinguish between children who are
Attendance of early childhood education: Percentage of children aged 36 to 59 in mainstream education and those who are in disability-specific educational
months who are attending an early childhood education programme. settings. This is significant since many countries have highly segregated
school systems for children with disabilities. For example, what is considered
Out-of-school rate: Percentage of children of: progression in a special education school may be significantly different from
• Primary-school age who are not attending early childhood education, that in a mainstream school, fundamentally altering responses to what is
primary school or higher considered ‘at level’ for the child. If this distinction could be captured, then
• Lower-secondary-school age who are not attending primary, lower- or the reported inequities between children with and without disabilities would
upper-secondary school or higher likely be even greater.
• Upper-secondary-school age who are not attending primary, lower- or
upper-secondary school or higher. Results related to upper-secondary-school attendance are based on children
who were less than 18 years old at the time of the survey. These results should
Books and reading: thus be interpreted carefully given that they do not include persons above the
• Percentage of children aged 7 to 14 years who have three or more books age of 18 who may still have been attending upper-secondary school.
to read at home
• Percentage of children aged 7 to 14 years who read books or are read to A final consideration is the fact that the denominators used for some
at home. indicators do not capture the entire population of children represented by the
sample. For example, out-of-school indicators only represent the situation
Definitions and data interpretation issues of children who have ever attended school. It is well known that the most
marginalized children in society, including those with disabilities, tend to be
Several methodological issues need to be addressed to accurately interpret overrepresented among those who are out of school, either because they
the findings in this chapter. have never attended school or because they have dropped out. Therefore,
the results that show disaggregated information on school progression for
A relevant consideration is the limitation of the data in providing a children with and without disabilities reflect the experiences of a subgroup of
comprehensive account of all factors affecting a child’s learning experience. children that, in all likelihood, face lower barriers to education than those who
While the indicators used here measure education uptake and outcomes, have never been able to attend school.
In Algeria and Tunisia, children with disabilities have a significantly lower attendance rate in early childhood education than children without disabilities
FIGURE 21 Percentage of children aged 36 to 59 months who are attending an early childhood education programme
51 31 35 22 15 2 3
7
Notes: Differences for Iraq and the State of Palestine are not statistically significant. Values for children with one or more functional difficulties in Tunisia are based on 25 to 49 unweighted observations.
At every level of education, in most countries, children with disabilities are more likely to be out of school than children without disabilities
FIGURE 22 Percentage of children of primary-school age who are not attending primary school or higher
3 3 5 5
1 0.5 7 13
Tunisia Algeria State of Palestine Iraq
FIGURE 23 Percentage of children of lower-secondary-school age who are not attending primary, lower- or upper-secondary school or higher
5 6
2 3 10 21 27
7
State of Palestine Algeria Tunisia Iraq
Note: Differences for Iraq and Tunisia are not statistically significant.
FIGURE 24 Percentage of children of upper-secondary-school age who are not attending primary, lower- or upper-secondary school or higher
19 27 13 28 20 29 36 48

In all countries except Iraq, children with disabilities are less likely to have three or more books to read at home
FIGURE 25 Percentage of children aged 7 to 14 years who have three or more books to read at home
5
59 50 34 27 27 19 7
Tunisia Algeria State of Palestine Iraq
Note: Differences for Iraq are not statistically significant.
In both the State of Palestine and Tunisia, children with disabilities are significantly less like to read books or be read to at home
FIGURE 26 Percentage of children aged 7 to 14 years who read books or are read to at home
80 70 52 38
Tunisia State of Palestine
Note: Data on this indicator are not available for Algeria and Iraq.
© UNICEF/UNI277687/Younis
Every child has the right to a happy

life, free from discrimination
Inequalities and negative outcomes for children

with disabilities often stem from discrimination,
harassment, stigma and negative stereotypes.9
© UNICEF/UN0611989/Ibarra Sánchez
EVERY CHILD HAS THE RIGHT TO A HAPPY LIFE, FREE FROM DISCRIMINATION 39
Indicators and data sources used in this

chapter
The country data presented in this chapter are drawn from

MICS conducted in Algeria, Iraq, State of Palestine and Tunisia
between 2018 and 2020.
Discrimination: Percentage of adolescents aged 15 to 17 years

who report having personally felt discriminated against or
harassed within the previous 12 months on the basis of disability
or on one of the other grounds for discrimination prohibited
under international human rights law.
Happiness: Percentage of adolescents aged 15 to 17 years who

are very or somewhat happy.
Definitions and data interpretation
One limitation regarding the results on discrimination and

subjective well-being is the high proportion of missing
information among children with difficulties in certain domains.
Since these data are collected through a questionnaire that
is directly administered to adolescents aged 15 to 17 years,
those with certain difficulties could not be interviewed due to
accommodation constraints during the survey implementation.
Another limitation regarding discrimination is the challenge

inherent in a perception-based question. While results for
discrimination can measure whether adolescents perceive that
they have been discriminated against, either because of their
disability or for another reason, these results cannot definitively
show whether discrimination actually occurred. For this reason,
results involving discrimination should be understood as being
based on perception.
© UNICEF/UN0276030/Herwig
In Tunisia, children with disabilities are more likely to feel discriminated against than children without disabilities
FIGURE 27 Percentage of adolescents aged 15 to 17 years who report having personally felt discriminated against or harassed within the previous 12 months on the basis of disability or on
one of the other grounds for discrimination prohibited under international human rights law
12 16 11 19 12 27
State of Palestine Iraq Tunisia
Notes: Differences for Iraq and the State of Palestine are not statistically significant. Data on this indicator are not available for Algeria.
Children with disabilities in Algeria and Iraq are significantly less likely to describe themselves as very or somewhat happy compared with children
without disabilities
FIGURE 28 Percentage of adolescents aged 15 to 17 years who are very or somewhat happy
85 80 80 64 75 60
State of Palestine Iraq Algeria
Notes: Differences for the State of Palestine are not statistically significant. Data on this indicator are not available for Tunisia.
EVERY CHILD HAS THE RIGHT TO A HAPPY LIFE, FREE FROM DISCRIMINATION 41
© UNICEF/UNI312019/Saleh
Fulfilling the rights of every child in

the Middle East and North Africa
Including children with disabilities in all

aspects of life must be a priority – in the
Middle East and North Africa as in the rest
of the world. Every child, everywhere, has
something to offer. His or her energy, talents
and ideas can make a positive difference to
families, communities and the world.
© UNICEF/UN0611912/Ibarra Sánchez
FULFILLING THE RIGHTS OF EVERY CHILD IN THE MIDDLE EAST AND NORTH AFRICA 43
Counting, documenting, understanding Finally, significant differences are found in subjective well-being between
children with and without disabilities. In Tunisia, children with disabilities are
Nearly 21 million children in the Middle East and North Africa have some form more than twice as likely to report feeling discriminated against compared
of disability. with children without disabilities. Similarly, in Algeria and Iraq, children with
disabilities are significantly less likely to report being very or somewhat happy
Comparable data from four countries in the region provide insights into the compared with children without disabilities.
characteristics and well-being of these children. While the proportion of children
with disabilities varies – from 12 per cent in the State of Palestine to 20 per Taken altogether, these data illustrate the deprivations experienced across the
cent in Tunisia – most children in all four of these countries have difficulties in Middle East and North Africa by children with disabilities. They also demonstrate
only one domain of functioning. Psychosocial difficulties, particularly signs of that their lived experiences vary significantly. Findings can provide a starting
anxiety, affect the largest share of children. point from which policies can be crafted to address inequities and ensure
equal opportunities for all children.
In many countries, children with disabilities have a greater likelihood of
experiencing adverse health and nutritional outcomes. In Tunisia, for example, From knowledge to action
children with disabilities are more likely to have had episodes of diarrhoea
or fever, or symptoms of an acute respiratory infection, in the previous two All children with disabilities deserve the opportunity to thrive. For this to
weeks compared with children without disabilities. The proportion of children become a reality, governments must consider the full range of needs of these
who experience malnutrition across the region is low. Children with disabilities children and their families in providing programmes and services. They need
in Iraq, however, are more likely to be underweight or stunted than their peers to work together with persons or associations of persons with disabilities to
without disabilities. ensure that:
Notable differences are found in the ways in which children with disabilities • All social services and environments are inclusive and accessible, so
are parented. In all four of the countries examined, children with disabilities that community-based care and assistance, critical information and
are less likely to receive adequate early stimulation and responsive care from opportunities to play and engage are available to every child, in times of
adults in their households. In Algeria, Iraq and Tunisia, children with disabilities stability as well as in humanitarian emergencies.
are significantly more likely to experience severe physical punishment from • Education is inclusive and accessible, so that children with disabilities can
caregivers than children without disabilities. In Iraq, the State of Palestine and go to school in their communities and learn alongside their peers without
Tunisia, mothers of children with disabilities are more likely to believe that disabilities.
physical punishment is needed to raise a child properly. • Children with disabilities are protected against violence, abuse, neglect
and exploitation, are able to benefit from birth registration and family
Children with disabilities in Algeria and Tunisia are substantially less likely to support, and can seek child-friendly, disability-inclusive support and
be attending an early childhood education programme, and in all countries, justice when their rights are violated.
children with disabilities are more likely to be out of school than their peers • Children with disabilities can access psychosocial support, so that they
without disabilities. Children with disabilities in the State of Palestine and are able to maintain their well-being and receive care for mental health
Tunisia are also less likely to have either three or more children’s books, or to issues such as anxiety and depression.
read or be read to at home.
• Stigma and discrimination against children with disabilities and their

families are eradicated, and the voices of children with disabilities are The Centre of Excellence on Data for Children
BOX 2
heard. with Disabilities
• Children with disabilities and their families are covered by adequate
social protection that supports their individual needs, links them with All countries should produce high-quality data on children with disabilities
critical services, and helps break the cycle of poverty, deprivation and at regular intervals. An important first step is adopting data collection
exclusion. instruments that measure the breadth and depth of functional difficulties that
• Parents and caregivers of children with disabilities receive support to children experience. Data should also capture the extent of the restrictions
they face in becoming active members of society. This means collecting
raise their children in the best way possible while maintaining their
additional data about the context in which they live, the barriers in their
own mental health and well-being. environment, the extent of their participation in different spheres, and their
• Robust, relevant and inclusive data are generated at regular intervals. access to core services and interventions. The collection of robust data on
children and adults with disabilities needs to extend to humanitarian settings
For every child, inclusion and also include children who are institutionalized or in street situations.
Counting all children requires the building of capacity so that quality

The extent to which children with disabilities are deprived, feel discriminated
standards are adopted worldwide for official disability statistics. Countries
against and lack hope for the future makes it clear that societies are not need support in their efforts to collect, analyse and disseminate data
doing enough to realize the most basic human rights of all children. As a on children with disabilities. This should include the engagement – and
result, the vicious cycle of exclusion and disadvantage that leaves children empowerment – of all relevant stakeholders, including organizations of
with disabilities behind continues. Knowing that the problem comes persons with disabilities.
down to barriers that society creates – which are a matter of choice, not
To support these efforts, UNICEF has launched the Centre of Excellence
immutable realities – means that there is potential for change. Part of that on Data for Children with Disabilities. The Centre will help fill data gaps and
change will involve celebrating children with disabilities and embracing meet the growing need for coordination, quality oversight and technical
diversity in all its forms. expertise in the field. It will support a broad range of activities to build the
capacity of data producers and data users, facilitate the development of
It starts right here, right now. When children with disabilities are seen new methods and tools, and support data collection, data analysis, data
interpretation and use, and knowledge generation.
and counted, they are no longer invisible, and the promise of inclusion
becomes a real possibility. The mission of the Centre is to enhance the ability of stakeholders to
make timely and data-driven decisions affecting children with disabilities. To
The steps in between depend upon every stakeholder. They involve achieve this mission, it will engage in a wide variety of activities, drawing on
shared responsibility, accountability and working together to ensure that the principles of partnership, innovation and inclusivity. The Centre is guided
all children, including children with disabilities, are able to achieve their by a Strategic Advisory Group composed of key stakeholders, who advise
on its activities and provide overall direction.
inherent potential.
The Centre has been founded with a global focus and commitment to the
above goals. This involves working with stakeholders across the globe,
including in the Middle East and North Africa.
FULFILLING THE RIGHTS OF EVERY CHILD IN THE MIDDLE EAST AND NORTH AFRICA 45
© UNICEF/UN057755/Izhiman
Technical annex
This report is based on UNICEF’s 2021 global report, Seen, Counted, Included: perceived short- or long-term loss of health associated with a condition and is
Using data to shed light on the well-being of children with disabilities. The not entirely aligned with the ICF definition of disability. This metric of disability
technical work behind that report aimed to produce estimates of the number of has been criticized for its lack of consideration of core participatory and rights-
children with disabilities aligned with the Convention on the Rights of Persons based principles and for being discriminatory on the value of persons with
with Disabilities and a biopsychosocial concept of disability. The regional and disabilities.12
global estimates presented here rely mainly on information about functional
difficulties or limitations among children gathered through sources with some Another limitation to this approach is that the weights attributed to each
degree of international comparability. While most of the data sources included impairment do not account for the differential impact that an impairment may
in the estimates refer to data collected from 2017 onwards, the data points have on various individuals as a result of environmental conditions.13 Since the
used for some countries are not the most recent ones, but those most aligned weights used by the Global Burden of Disease do not vary across geographic
with the concept of disability underlying the global estimate. regions, they disregard the multiple contextual factors that can worsen
functionality in persons with the same impairments.14
Until the 2021 report, no estimation of the global number of children with
disabilities had been made that takes into account a broad range of functional The use of medical concepts of disability also has implications for the quality of
difficulties along with behavioural and mental health issues. data. Reporting of these impairments usually depends on parents’ awareness
of symptoms and a pre-existing diagnosis. Therefore, under-identification
The only estimate available for many years indicated that 10 per cent of the remains a problem since diagnosis depends on the availability of health-care
world’s population had some form of disability.10 In 2011, this was updated to facilities where children can be screened.
15 per cent, and an estimate was produced on the number of children aged
14 or younger with a moderate or severe disability: 93 million children, or 5 More recent estimates have introduced improvements, such as increasing
per cent of children in that age group.11 Such global estimates are affected by the internal consistency of different sources of data by using a meta-analytic
well-known limitations surrounding disability measurement. approach and adjusting estimates for comorbidity.15 That said, these latest
estimates are still largely focused on the burden of different impairments and
The concept of disability described in the WHO’s Global Burden of Disease medical conditions, rather than on the functional difficulties or restrictions to
2004 (upon which the 2011 estimate for children is based) refers to the participation experienced by children with disabilities.
TECHNICAL ANNEX 47
© UNICEF/UN0581232/Almatar
How data were selected or health conditions. Another selection criterion was the use of a rating scale
to capture the severity of functional difficulties, rather than the use of ‘yes’ or
UNICEF maintains a global database of disability data sources from 194 ‘no’ questions.
countries. The database includes more than 1,000 data points together with
information on methodological aspects that can impact the number of children On the basis of these considerations, and in consultation with experts,
who are identified as having a disability. The selection of data sources involved 103 data sources (one per country) were selected, including 10 sources for
an extensive process of data compilation and consultations with country-level countries in the Middle East and North Africa. Collectively, these data sources
experts to overcome limitations on data availability and comparability, and to represent 84 per cent of the world’s population of children and at least 50 per
ensure their views were reflected in the data selection, harmonization and cent of the population of children within each region (Table 3).
estimation process.
Technical consultations
After screening the disability global database, sources of data collected prior to
2005, as well as those not derived from censuses or household surveys, were Heterogeneity across data sources is a common concern when generating
excluded. An additional selection criterion focused on identifying data aligned global estimates. While this can be dealt with using a strictly statistical
as closely as possible with the concept of disability described earlier. This approach, incorporating country-level expertise into the data selection and
meant selecting sources of data gathered through measurement tools that harmonization process was considered important.
collect information on functional difficulties rather than specific impairments
TABLE 3 Countries and areas, population coverage and data collection instruments
Countries and areas Type of instrument

Percentage
Number of child Global
Total Child Functioning Washington Group
included in the Activity Limitation Other
number population Module Short Set
analysis Indicator
East Asia and the Pacific 33 16 80 10 5 0 1
Eastern and Southern Africa 25 13 74 5 7 0 1
Europe and Central Asia 55 31 59 9 1 20 1
Latin America and the Caribbean 37 14 74 10 3 0 1
Middle East and North Africa 19 10 73 5 5 0 0
North America 2 2 100 2 0 0 0
South Asia 8 5 96 3 1 0 1
West and Central Africa 24 12 74 9 3 0 0
Total 203 103 84 53 25 20 5

TECHNICAL ANNEX 49
The estimation work was part of an iterative process that included three instruments are typically implemented under different conditions. For example,
technical consultations with experts in the field of data on children with while the Child Functioning Module is intended to be administered to the
disabilities. They included professionals from national statistical offices, child’s mother (or if the mother is deceased or living in another household,
organizations of persons with disabilities and academia. to the child’s primary caregiver), the Short Set is typically administered to the
household head. Table 4 shows the differences in the estimates generated by
Following a standard protocol, the consultation sought to obtain the experts’ the two instruments in seven countries.
views on the prevalence of children with functional difficulties in their
countries. The initial part of the consultation was dedicated to building a To correct for the underestimation of the percentage of children with
common understanding of disability aligned with the ICF and the Convention disabilities, the data points based on the Short Set were adjusted. The
on the Rights of Persons with Disabilities. This was followed by in-depth process was as follows. First, microdata from 36 countries that used the Child
discussion of the available country-level information and the results of the data Functioning Module were processed to generate country-level results of the
harmonization analyses and estimation work. For each consultation, UNICEF percentage of children aged 5 to 17 years identified as having one or more
shared details on the process and methodology used for estimations as well functional difficulties based on: (a) the full set of 12 functional domains, and
as on the selected data sources for each region and country/area. Experts’ (b) the subset of 6 functional domains that are common to the two measures.
inputs in relation to the data harmonization approach were incorporated and Second, linear regression models were used to predict country-level results
reflected in the regional and global estimates. for the 12 functional domains based on the country-level results of the 6
functional domains and the country’s under-five mortality rate.
Data harmonization
Harmonization of age groups: Results by age group were harmonized to

match the Child Functioning Module’s age groups (children aged 2 to 4 years
and 5 to 17 years). For some data sources, prevalence for the harmonized age
TABLE 4 Percentage of children aged 5 to 17 years with functional difficulties measured by
groups was calculated directly from empirical results available at the country the six domains covered by the Short Set, by the same six domains in the Child Functioning
level. For the remaining sources, the harmonized results by age group were Module and by the 12 domains in the Child Functioning Module
obtained using weighted averages of the data points available.
Washington Group Child Functioning Child Functioning
Adjustment of the Washington Group Short Set: Instruments that collect data Short Set Module Module
(6 domains) (6 domains only) (12 domains)
based on a restricted number of functional domains tend to underestimate
Costa Rica 4.0 7.1 21.1
the proportion of children with disabilities. Results from several countries that
used both the Child Functioning Module and the Washington Group Short Guyana 2.2 5.6 17.5
Set show that the number of children aged 5 to 17 years who are identified Mexico 1.5 4.1 11.2
as having functional difficulties by the six domains covered by the Short Set
Pakistan 2.5 5.0 17.9
is substantially lower than the number identified by the 12 domains included
in the Child Functioning Module (Table 4). While this underestimation is State of Palestine 1.5 3.0 14.9
mostly due to the larger number of domains in the Child Functioning Module, Tonga 1.4 2.7 9.8
other sources of underestimation should be considered, given that the two Zimbabwe 4.7 4.9 10.1
Imputation of the estimate for children under 2 years of age age groups. Country-level prevalence rates were transformed into the number
of cases using the child population. Regional estimates were generated using
Data on disability among children under the age of 2 are scarce. To date, random effects models considering that, despite harmonization efforts, the
no questions on functional difficulties have been validated that could be methods used to estimate the prevalence of disability were heterogeneous.
implemented to collect data about very young children in surveys and generate This approach also assumed that prevalence estimates from countries that
results that are reliable and comparable cross-nationally. While most severe could not be included in the analysis were better informed by the random
impairments manifest early, sometimes even before children are born, many effects model. Random effects meta-analysis incorporates the heterogeneity
functional difficulties only become evident as children grow up. Measuring of prevalence across countries rather than relying on the prevalence of
functional difficulties in children under the age of 2, in the context of surveys larger countries, as assumed by the fixed effects model. The only exception
or censuses, is thus complicated since mothers or primary caregivers might was the North America region, where the two countries that constitute the
not be aware of such difficulties, especially if these are not severe. Yet, region (Canada and the United States) used the same instrument and a fixed
excluding children under this age would lead to a systematic underestimation effects model was used. For all other regional estimates, random effects
of the number of children with disabilities. Estimates of major and severe were utilized to incorporate the within- and between-country variability. The
impairments at birth among surviving children, and neurodevelopmental regional estimates were then used to generate the population-weighted
and cognitive impairments among babies born pre-term and full-term, range global estimate (Table 5).
between 2.4 per cent and 2.8 per cent.16 Even though these estimates are
restricted to more severe impairments and conditions, they provide evidence Analysis using country-level microdata
that functional difficulties are to be expected from birth at a prevalence of at
least that magnitude. Finally, since some functional difficulties only become All data were obtained from publicly available MICS datasets. MICS survey
evident to mothers as children grow older, it is also reasonable to expect design follows a probabilistic, clustered, stratified and multi-stage sampling
that, among those under 2 years, there is a higher proportion of children with approach to generate population-level indicators that are representative at the
functional difficulties than reported. Therefore, based on these considerations, national level, urban-rural and other domains (usually regions), according to
it seemed reasonable to assume that the estimate for children under the age the country-specific stratification strategy.
of 2 could be informed by the estimate for children aged 2 to 4 years in each
country. As of September 2022, data were available across four countries in the
Middle East and North Africa. Data processing was conducted to generate
Estimation of the regional and global number of children with the child functioning variables, more than 40 standard indicators, and relevant
disabilities disaggregation variables.
The estimations use a meta-analytical approximation to calculate the regional Results for country analyses that are based on 25 to 49 unweighted
and global number of children with disabilities. Meta-analysis of proportions observations should be interpreted with caution. Within figures, all numbers
was implemented using the prevalence rates of children with disabilities for except those valued under one were rounded to the nearest whole value.
each country, 95 per cent confidence intervals and the child population for all
TECHNICAL ANNEX 51
TABLE 5 Regional and global estimates
Children aged 0 to 4 years Children aged 5 to 17 years Children aged 0 to 17 years
Number of children Number of children Number of children

Lower Upper Lower Upper Lower Upper
% with disabilities % with disabilities % with disabilities
bound bound bound bound bound bound
(in thousands) (in thousands) (in thousands)
East Asia and the Pacific 3.5 3.3 3.8 5,333 9.5 7.5 11.6 37,788 7.8 6.7 9.1 43,121
Eastern and Southern Africa 5.2 4.5 6.0 4,509 12.8 11.2 14.4 24,356 10.4 9.5 11.3 28,865
Europe and Central Asia 2.7 2.4 3.1 1,515 6.5 5.6 7.4 9,299 5.5 4.9 6.0 10,814
Latin America and the Caribbean 3.8 3.3 4.5 1,978 12.6 11.5 13.7 17,102 10.2 9.6 10.8 19,080
Middle East and North Africa 4.5 3.3 6.0 2,246 16.9 13.5 20.5 18,694 13.1 11.3 15.1 20,940
North America 4.4 3.9 4.9 943 12.0 11.3 12.7 7,073 9.9 9.5 10.4 8,016
South Asia 3.7 2.9 4.7 6,254 13.0 10.2 16.1 58,177 10.5 9.0 12.2 64,431
West and Central Africa 6.8 5.8 7.9 6,139 18.9 15.3 22.7 34,944 14.9 12.8 17.2 41,083
World 4.3 4.1 4.6 28,917 12.5 11.7 13.3 207,433 10.1 9.7 10.6 236,350
Countries in the Middle East and North Africa region include Algeria, Bahrain, Egypt, Iran (Islamic Republic of), Iraq, Israel, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Qatar, Saudi Arabia, State of Palestine,
Syrian Arab Republic, Tunisia, United Arab Emirates and Yemen. For a complete list of countries and areas in the regions and subregions, see <data.unicef.org/regionalclassifications>. Demographic data are from:
United Nations, Department of Economic and Social Affairs, Population Division, World Population Prospects 2019, Rev. 1, online edition.
Endnotes
1. United Nations Children’s Fund, ‘Producing Disability-Inclusive Data: Why it matters and what it takes’, UNICEF, New York, 2020.
2. The inclusion of questions regarding children younger than 2 years was one objective of the Child Functioning Module. However, to date, no universal functioning questions have
been identified for these very young children that could be implemented in surveys and that would elicit valid, reliable and cross-nationally comparable results.
3. Loeb, Mitchell, et al., ‘The Development and Testing of a Module on Child Functioning for Identifying Children with Disabilities on Surveys. I: Background’, Disability and Health
Journal, vol. 11, no. 4, 2018, pp. 495-501.
4. Massey, Meredith, ‘The Development and Testing of a Module on Child Functioning for Identifying Children with Disabilities on Surveys. II: Question development and pretesting’,
Disability and Health Journal, vol. 11, no. 4, 2018, pp. 502-509.
5. International Disability Alliance, ‘Joint Statement by the Disability Sector: Disability data disaggregation’, <www.internationaldisabilityalliance.org/data-joint-statement-march2017>,
accessed 19 May 2021.
6. The Washington Group Short Set is comprised of questions on difficulty with functioning in six basic activity domains (seeing, hearing, walking, remembering or concentrating,
washing all over or dressing, and communicating), and each has four possible response categories (no difficulty, some difficulty, a lot of difficulty and cannot do at all).
7. United Nations, Universal Declaration of Human Rights, United Nations, Paris, 10 December 1948, article 3; United Nations, Convention on the Rights of the Child, United Nations,
New York, 20 November 1989, article 23; United Nations, Convention on the Rights of Persons with Disabilities, 30 March 2007, United Nations, New York, articles 10 and 25.
8. World Health Organization, United Nations Children’s Fund and World Bank Group, Nurturing Care for Early Childhood Development: A framework for helping children survive and
thrive to transform health and human potential, WHO, Geneva, 2018. Responsive care refers to interactions that are emotionally supportive and entail engagement of a child with a
parent or caregiver; they can include responsive feeding, playing, singing or talking. See United Nation’s Children Fund, Early Moments Matter for Every Child, UNICEF, New York,
2017.
9. Mepham, Sarah, ‘Disabled Children: The right to feel safe’, Child Care in Practice, vol. 16, no. 1, 2010, pp. 19-34; Smythe, Tracey, Jaimie Adelson and Sarah Polack, ‘Systematic Review
of Interventions for Reducing Stigma Experienced by Children with Disabilities and Their Families in Low- and Middle-Income Countries: State of the evidence’, Tropical Medicine and
International Health, vol. 25, no. 5, 2020, pp. 508-524.
10. World Health Organization, ‘Disability Prevention and Rehabilitation: Report of the WHO Expert Committee on Disability Prevention and Rehabilitation’, Technical Report Series 668,
WHO, Geneva, 1981.
11. World Health Organization, World Report on Disability, WHO, Geneva, 2011.
12. Arnesen, Trude, and Erik Nord, ‘The Value of DALY Life: Problems with ethics and validity of disability adjusted life years’, British Medical Journal, vol 319, no. 7222, 1999, pp. 1423-
1425.
13. Anand, Sudhir, and Kara Hanson, ‘Disability-Adjusted Life Years: A critical review’, Journal of Health Economics, vol. 16, no. 6, 1997, pp. 685-702.
14. Mont, Daniel, ‘Measuring Health and Disability’, The Lancet, vol. 369, no. 9573, 2007, pp. 1658-1663.
15. Olusanya, Bolajoko O., et al. ‘Global Burden of Childhood Epilepsy, Intellectual Disability, and Sensory Impairments’, Pediatrics, vol. 146, no. 1, 2020, pp. 1-17.
16. Bourke, Jenny, et al., ‘Predicting Long-Term Survival without Major Disability for Infants Born Preterm’, The Journal of Pediatrics, vol. 215, 2019, pp. 90-97.
53
© UNICEF/UNI156079/Noorani
United Nations Children’s Fund
Data and Analytics Section
Division of Data, Analytics, Planning and Monitoring
3 United Nations Plaza
New York, NY 10017, USA
Email: [email protected]
Website: data.unicef.org

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Children with Disabilities in

the Middle East and North Africa:

Permission is required to reproduce any part of this publication. Permission will be

UNICEF Data and Analytics Section

Census (1984) - Census (1994) - Census (2014) - MICS (2018) -

Every child has the right

Data provide the foundation for

Indicators and data sources used in this chapter These include:

FIGURE 3 Number of children aged 0 to 17 years with disabilities

South Asia West and Central Africa Eastern and

Middle East and Latin America and Europe and

Tunisia Iraq Algeria State of Palestine

Tunisia Iraq Algeria State of Palestine

Tunisia Iraq Algeria State of Palestine

Tunisia Iraq Algeria State of Palestine

Note: Differences for Tunisia are not statistically significant.

Poorest 20% Richest 20%

Tunisia Iraq Algeria State of Palestine

Tunisia Algeria Iraq State of Palestine

Tunisia Iraq Algeria State of Palestine

Algeria Iraq State of Palestine Tunisia

Every child has the right

All children have the right to survive and develop,

Indicators and data sources used in this chapter

Prevalence of acute respiratory infection (ARI) symptoms: Percentage of

Prevalence of diarrhoea: Percentage of children aged 24 to 59 months for

Prevalence of fever: Percentage of children aged 24 to 59 months for whom

Moderate and severe underweight prevalence: Percentage of children

Moderate and severe stunting prevalence: Percentage of children aged 24

Definitions and data interpretation issues

Findings on disease symptoms and reported disease episodes also present

Findings on nutritional status should also be interpreted with caution.

Algeria Iraq Tunisia State of Palestine

Algeria Tunisia State of Palestine Iraq

Algeria State of Palestine Iraq Tunisia

Tunisia State of Palestine Algeria Iraq

State of Palestine Tunisia Algeria Iraq

Every child has the right to a nurturing

All children have the right to grow up

Severe physical punishment: Percentage of children aged 2 to 14 years who

Attitudes towards physical punishment: Percentage of mothers of children

Definitions and data interpretation issues

An overarching limitation that runs through some of the indicators regards

State of Palestine Tunisia Algeria Iraq

Tunisia State of Palestine Algeria Iraq

State of Palestine Tunisia Iraq Algeria

Note: Differences for Tunisia are not statistically significant.

Algeria State of Palestine Tunisia Iraq

Algeria Iraq State of Palestine Tunisia

Every child has

Education provides children with the

Tunisia State of Palestine Algeria Iraq

Tunisia Algeria State of Palestine Iraq

Note: Differences for Tunisia are not statistically significant.

State of Palestine Algeria Tunisia Iraq

Tunisia State of Palestine Algeria Iraq

Tunisia Algeria State of Palestine Iraq

Note: Differences for Iraq are not statistically significant.

Tunisia State of Palestine