Process evaluation of the Disability Allowance programme in the Maldives

Limited evidence on the design and implementation of social protection programmes for people with disabilities in low-and middle-income countries constrains understanding of how their impacts could be improved. The Disability Allowance programme in the Maldives is a non means-tested, monthly cash transfer targeting people with disabilities. Using qualitative methods, process evaluation was used to examine the intervention design, implementation, and likelihood of achieving its intended objectives. There were important strengths of the programme, including the broad de ﬁ nition of disability. We ﬁ nd that delivery could be strengthened through providing greater clarity on eligibility criteria and strengthening human resources to widen the programme ’ s reach. Intervention ﬁ delity was challenged by inconsistent practice among implementers and lack of established protocols. Most importantly, the absence of linkages with the Medical Welfare scheme that provides assistive devices potentially limits the likelihood of the programme achieving intended objectives.


Introduction
The World Report on Disability estimates that there are over one billion people with disabilities in the world, of whom 110-190 million experience very significant difficulties (WHO and World Bank, 2011). 1 Poorer people, and people living in poorer countries, are more likely to become disabled, for instance, through lack of healthcare or living in unsafe environments (Banks, Kuper, and Polack, 2017).Generally, people with disabilities are often excluded from education and employment and incur additional costs because of their disability, leading to or exacerbating poverty (WHO and World Bank, 2011).There is clear evidence that people with disabilities are on average poorer than their peers without disabilities.A recent systematic review found that over 81 per cent of 150 studies identified from low-and middle-income countries (LMICs) found a positive, statistically significant association between disability and economic poverty (Banks, Kuper, and Polack, 2017).That this relationship persisted across age groups, location, disability types and study designs provides strong support for the notion of a "disability-poverty" cycle, in which disability is both a potential cause and consequence of multiple dimensions of economic and social exclusion.
The United Nations 2006 Convention on the Rights of Persons with Disabilities (CRPD) 2 recognizes the role of social protection in alleviating poverty and promoting the full and effective participation of people with disabilities.Following a 2018 draft Joint Statement, the International Labour Organization (ILO) and International Disability Alliance (IDA) facilitated what has come to be known as the "2019 Joint statement towards inclusive social protection systems supporting full and effective participation of persons with disabilities" (ILO and IDA, 2019).The Joint Statement reinforces the commitment towards inclusive social protection systems, reflecting a shared commitment among several governments, United Nations (UN) agencies, civil society and academia.Governments in LMICs are increasingly implementing social protection programmesparticularly social assistance (i.e.transfers of cash or benefits in kind)to tackle poverty amongst people with disabilities (Barrientos and Hulme, 2009).Overall, 170 countries have established periodic cash benefit

Social protection and disability in the Maldives
The Maldives is an island nation with a population of around 400,000 people, a third of whom live in Malé, the capital city.The remaining are dispersed across 188 islands, making equitable service provision and economic diversification difficult (National Bureau of Statistics, 2014).Although it is categorized as an upper-middle income country, with a GDP per capita of $11,151 in 2017, 3 high degrees of inequality remain (Ministry of Health and Inner City Fund, 2018).
Data is lacking on the prevalence of disability in the Maldives.A survey undertaken in 2003 measuring disability in terms of different types of impairment (e.g.hearing, vision, speech) reported that 3.4 per cent of the population were considered to have a disability (Ministry of Gender Family Development and Social Security, 2003).This is likely to have been an underestimation of the prevalence of disability, because not all impairments were included or would have been diagnosed.More recently, the Maldives Demographic and Health Survey 2016/17 indicated a 4 per cent prevalencehowever, this survey asked respondents whether they "suffer from a disability".Given that respondents may have been reluctant to declare a disability, for example due to stigma, the survey is also likely to have underestimated disability prevalence (Ministry of Health and Inner City Fund, 2018).In comparison, it is notable that the estimated prevalence of moderate or severe disability for Southeast Asia from the World Report of Disability is 16 per cent (WHO and World Bank, 2011).
The Maldives ratified the CRPD in 2010.The national policy environment for social protection for people with disabilities is framed by article 17 and article 35 of the 2008 Constitution of the Republic of Maldives, 4 and by the Protection of the Rights of Persons with Disabilities and Provisions for Financial Assistance Act (or Disability Act). 5 The Social Protection Act of 2014 formalized the pre-existing support (e.g.once only lump-sum cash assistance) that had been provided by the President's Office in the early 2000s. 6Provisions under the Act include non-discrimination in health, education, employment services, improving access to health, state provision of assistive devices and facilitating basic needs through a cash transfer mechanism.This cash transfer, or Disability Allowance, is a monthly, non-conditional, non-means tested benefit of 2,000 Maldivian rufiyaa (MVR) (approx.130 US dollars (USD) in 2021).
The Disability Allowance programme is administered by the National Social Protection Agency (NSPA) (IPC-IG and UNICEF, 2019)

Methods
The objective of the process evaluation was to gain a better understanding of the design and implementation of the Disability Allowance programme, complementing the wider impact evaluation of the same programme.Process evaluations are aimed at exploring the "black box" of intervention design and effectiveness, examining which components have worked, and which have not (Linnan and Steckler, 2002).As there is no single set of prescribed steps or methods for process evaluations, the Medical Research Council (MRC) framework provides useful guidance on aspects that can be explored in process evaluations of complex interventions (Moore et al., 2015).Using this MRC framework, we examine the design, implementation, and factors enabling or inhibiting the programme in achieving its outputs and final objectives.Key stages of this process evaluation, methods and timeline are depicted in Figure 1.The components highlighted are the focus of this article.

Context
Contextual information (e.g.policies, changes to legislature or policy-makers) was updated throughout the study period through continuous engagements with implementers and stakeholders.Initially, this data was collected through documentary analysis, analysis of routine data, a site visit to a mental health facility, and six stakeholder meetings including government and civil society.

Development of a logic model and causal assumptions
This process was undertaken in May 2016, first through a workshop for the implementers (NSPA) and other stakeholders (Ministry of Law and Gender, UNICEF, Care Society, Ministry of Planning, Health Protection Agency) to develop a "Theory of Change" capturing the underlying causal assumptions.

Implementation
Data to assess implementation of the Disability Allowance -"what is implemented, and how" (Moore et al., 2015) involved 25 in-depth key informant interviews.

Process evaluation of the Disability Allowance programme in the Maldives
These included ten implementers, seven stakeholders (Ministry of Law and Gender, Health Protection Agency, officials from the Island Council Office and Island Health Centre, and civil society members), and eight programme beneficiaries.
Participant selection was undertaken carefully, ensuring that they represented key personnel involved in all levels of the programme: those who make decisions about the programme, those implementing the programme (both centrally and in the community), stakeholders involved in facilitating uptake of the programme, and those enrolled in the programme.Participants were selected through purposive sampling based on their roles (for key informants) and gender, broad age-group, and type of impairment (for beneficiaries).
Interview guides were used to standardize the information collected across groups.The beneficiaries were interviewed in relation to their experience of enrolling in the Disability Allowance.Interview guides used for programme implementers and decision-makers were tailored to the individual's role in the design and delivery of the Disability Allowance.All interviews were conducted in the preferred language of the interviewee and were usually audiotaped.Compensation was not given for interview participation.

Data analysis
Data were analysed through an inductive process.At the end of each interview, a summary was prepared.The summaries were read immediately, and potential trends and patterns were noted (Pope, Ziebland and Mays, 2000).The data relevant to each category were organized under general themes (e.g.assessment of disability, knowledge about social protection, uptake of programme) and areas where a consensus exists were highlighted.All data were evaluated against the "Theory of Change" model, and analysis was conducted in the language of the interview (Dhivehi or English) to prevent information being lost in the translation process.Specific quotes were identified and translated to illustrate key points.

Ethical considerations
This study was approved by the ethics committee of the London School of Hygiene & Tropical Medicine and the National Health Research Committee in the Maldives.All data were kept confidential and anonymized.We sought written informed consent before each interview and emphasized that participation was voluntary.

Results
The results are presented in four main parts.First, we discuss the design of the Disability Allowance programme and its intended outcomes (i.e. the policy intervention).Next, we examine how it is delivered and, then, what is delivered.Finally, we examine the context.

Intervention
The Disability Allowance in its existing form was established in 2010 following the Disability Act, which was designed in line with the CRPD (Government of Maldives, 2010;United Nations, 2006).The objective of the Allowance is "to protect and provide disabled citizens the same rights and opportunities as any other citizen". 7The Act states that "all persons with long-term physical, psychological, sensory or mental illness facing difficulty in participating [in] community activities to the same level as others shall be considered as persons with disabilities" (Government of Maldives, 2010), which is in line with the CRPD definition (United Nations, 2006), and includes people with a broad range of impairments.
The Disability Allowance covers all registered persons with disabilities in the Maldives who are Maldivian citizens, and application is on a rolling basis.Once beneficiaries are registered for the Allowance, they receive approximately MVR 2,000 (USD 130) into a nominated bank account on a monthly basis.The application process and difficulties associated with this are described below in the section on Mechanisms.
The NSPA also runs the Medical Welfare scheme, which offers assistance to people with and without disabilities.This assistance includes the provision of assistive devices and medication where these are not already covered under Aasandha, the national health care financing scheme.Assistive devices provided through Medical Welfare can be replaced, but only on a fixed schedule rather than on request (e.g.every three years for hearing aids or annually for wheelchairs).
Recipients of the Disability Allowance are also eligible to receive other types of social protection.In particular, all people aged 65 or older are enrolled in the Old Age Pension and receive MVR 5,000 (approx.USD 320) per month.People with disabilities may also receive other benefits such as priority in the allocation of housing and services or vocational training.
A disability benefit card provided by the Ministry of Gender also allows people with disabilities priority service in queues in government offices, as well as to access services from Senahiya, the medical facility for uniformed bodies (e.g.armed forces 7. See the NSPA website. Process evaluation of the Disability Allowance programme in the Maldives and police personnel).As of 2019, the disability benefit card is issued by NSPA and all persons registered for the Allowance are eligible for the card, whereas previously these were not linked, and the beneficiaries did not intersect.
The research team and programme implementers (NSPA) constructed a "Theory of Change" for the Disability Allowance collaboratively.The model depicted in Figure 2 outlines that if certain activities are undertaken (the boxes on the left indicating elements of the programme), then certain outcomes are expected to be achieved (shaded boxes), when particular assumptions are fulfilled.
Three key outcomes are identified for the programme, based on the positive effects of social protection highlighted by previous studies (Figure 2): • A reduction in household poverty is expected to be achieved as a direct result of the monthly allowance, as well as through improved productivity of the person and his/her household resulting from better access to healthcare and financial resources (Kuper et al., 2010).
• Improved participation of beneficiaries with disability are anticipated, as their functioning will improve through the provision of assistive devices and medical care and as funds are made available to support travel and assistance (Polack et al., 2010b).
• Improved quality of life is anticipated as an indirect result of reduced household poverty, through improved health (from better access to health care and ability to buy "good foods"), ability to hire a caregiver, and greater empowerment and dignity as the person feels that they are valued in the household (Polack et al., 2010a).
A number of assumptions underlie this presented "Theory of Change".The first is that the amount received is sufficient to reduce poverty and cover costs for needed disability-related goods and services.In turn, appropriate staff are available to deliver the Disability Allowance and that money is available to support the programme adequately.Further, it is assumed that people enrolled in the programme receive both a monthly allowance as well as any necessary referrals for medical care and/or assistive devices.

How is it delivered?
Analysing the implementation processhow an intervention is deliveredinvolves examining the structures and mechanisms through which delivery is achieved (Moore et al., 2015).
Mechanisms.This covers seven important areas: i) information about the programme; ii) application process; iii) eligibility determination; iv) enrolment; v) appeal, grievance and redress mechanisms; vi) monitoring; and vii) information system and data storage.

Process evaluation of the Disability Allowance programme in the Maldives
International Social Security Review, Vol.75, 1/2022 • Information about the programme.This information is made available on the NSPA (implementer) website and is mostly communicated to the general public through limited activities such as event-based information stalls or activities to commemorate special days.
• Application process.People believed to have disabilities can undergo a medical or psychological assessment by a relevant health specialist, who then may provide a medical certification of an assessed disability.For the Disability Allowance, this medical report is submitted as supporting documentation alongside a completed application form.If additional information is required, this must be provided within three months or applicants must re-submit their application with new supporting documentation (including a new medical report if the original is over 12 months' old).
• Eligibility determination.Disability Allowance applications, once received by the NSPA, are routed to the Disability Unit (explained in the section on Actors).Once the application is verified for completion, senior staff make a decision as to whether further checks are necessary.If no further checks are required by the NSPA, the application is ready to be reviewed by the Disability Committee.Some applications may require observation for verification (e.g.applicants who are unable to leave their home), which is carried out by NSPA staff for Malé-based applicants, and by Island Council staff for other island-based applicants.
Other applications may require functional assessments (most commonly for people with physical or sensory impairments), which are often conducted through telephone interview.Functional assessments are based on the Disability Certification and Assessment Guideline (NSPA, 2010) and involve assigning scores to activity limitations such as mobility, communication and self-care.These scores inform the decision by the Disability Committee to accept or reject the application.Although functional assessments should better align eligibility with the CRPD, rather than being based on a strict documentation of medical impairments, there are gaps in its implementation.These include inadequate training among those conducting the functional assessments (see section on Actors), and a lack of written guidance or protocols to guide decisions on which impairment types or applications require verification or which need to be routed for functional assessments.Key informants from the NSPA described how they lacked clear documented guidance on assessment protocols, which resulted in them "creating it on our own".This process could lead to inconsistent implementation of assessments and application decisions.
For Medical Welfare, applicants must submit a form, medical documentation verifying the need for the assistive device or medication, and three price quotations from different vendors if the NSPA or the State Trading Organization (STO) do not stock the device or drugs.Successful applicants are then provided with the device by the NSPA or STO, or given money to purchase the device or drugs directly.This process previously took seven or eight working days for a decision, but now takes 24 hours.
• Enrolment.Successful applicants for the Disability Allowance are informed via text message.The cash transfer is deposited, beginning the next calendar month, directly into an authorized bank account (either the disabled person's bank account or that of their parent or guardian).Beneficiaries are entitled to continue receiving the cash transfer for as long as they remain eligible (i.e.unless their condition changes).There are no formal adherence or compliance conditions for either programme (e.g.restrictions on working, which exist for social protection schemes in other countries).
• Appeal, grievance and redress mechanisms.For the Medical Welfare scheme, senior staff make time available on a daily basis for anyone who wishes to make a complaint about the scheme.The NSPA operates a toll-free helpline that serves as a point of contact, including about applications.At the time of data collection, there was no formal process for appealing decisions in place.
• Monitoring.Monitoring is primarily restricted to checks carried out by NSPA staff confirming eligibility for the scheme or confirming deaths among beneficiaries.A number of key informants noted that the legacy list of beneficiaries handed to the NSPA from the Ministry of Gender contained a number of people who were not assessed as disabled.Given that these people had received support (e.g.once only lump-sum cash assistance) from the President's Office prior to the establishment of the NSPA and the establishment of the current eligibility criteria, entitlements are being verified during island monitoring visits, with the aim of removing those who are ineligible.Knowledge of this additional verification process has been shared word-of-mouth and has acted to reinforce the perception that the Allowance payment can be irregular, or could be discontinued, or that additional steps need to be taken to continue receiving it.
• Management Information System and data storage.Information about beneficiaries is currently stored on Excel sheets as well as a designated software package for managing this database.Data collected includes personal information, type of disability and when the disability was first diagnosed, and bank account details.At the time of data collection, this list of beneficiaries is the only national "database" of people with disabilities (the implications for which are discussed later, under Context).As a result, it is reported as common practice to share an updated list with government authorities (such as the Ministry of Gender, or the National Disaster Management Centre) when requested.Thus, while this information enables effective government interventions, the extent to which data confidentiality is CRPD-compliant (article 31) is unclear.
Actors.In this section, we examine the actors (Disability Unit; Monitoring section; Medical Welfare department; Disability and Welfare Committees; Island Councils and Health Centre staff; and specialist health professionals) involved in the delivery of the Disability Allowance, their intended roles, and intervening factors that inhibit or enable programme delivery.This information is summarized in Table 1.
• Disability Unit.At the time of data collection, this unit comprised of three administrative staff supervised by one senior member of staff.Two administrative staff reported having received training for their roles, primarily through "on the job" support, while one staff member also received one short-term training.Some key informants considered this training limited, which is concerning given the critical role they play in shaping the outcome of Disability Allowance applications.For example, their decision to conduct a functional assessment could potentially extend the application process and complicate it for some applicants not living in Malé.
• Monitoring section.The section's staff conduct the functional assessments when requested by the Disability Unit, which inform decisions on acceptance to the Disability Allowance programme.Yet, they too seem to lack training proportionate to their roles, having received only a 2-3 hour training conducted in-house by various members of staff who had previously done the work.
Although training is based on the Disability Certification and Assessment Guideline, the NSPA staff report that the training guidelines have not been documented to ensure that the same content is being provided in each training.
• Medical Welfare department.The department that provides assistive devices is located separately to the Disability Unit and comprises six staff supervised by a senior staff member.Notably, staff report that they do not typically refer applicants to the Disability Allowance; this is something that was similarly reported by Disability Unit staff.This lack of formal connection between the two programmes is a limiting factor that restricts the number of people who access both schemes.
• Disability and Welfare Committees.These Committees make the final decisions to approve or reject Disability Allowance and Medical Welfare applications.Prior to the Committees being established, these decisions were made by senior staff at the NSPA.The current, revised decision-making process seeks to address the perceptions of personal bias associated with the previous system, where personal and informal knowledge of applicants may have influenced decisions.
• Island Councils and Health Centre staff.These island-based government staff are expected to be sources of information about the Disability Allowance.However, these actors appear to provide differing levels of support to applicantssome may just provide application forms while others actively checked application status.These differences appeared to reflect individual attitudes to the support they felt should be provided, rather than formal institutional roles.Moreover, concerns about the objectivity of island staffthat they might prioritize the needs of community members without regard for the rules of the scheme, or be reluctant to be involved in any decision that denies a person eligibilityalso limit the formal role that these actors play.This is conveyed by the following quote: (-) Information gaps-some did not know they could assist (-) Varied assistance-some provided minimal help, others actively helped with application (-) Gatekeeper effect-some applicants dissuaded from applying due to personal biases 5) Health Centre staff • Inform individuals about eligibility (-) Other stakeholders question their objectivity 6) Specialist health professionals • Provide medical certification needed for application (-) Limited number of specialists and impairment-specific services available throughout the country Source: Authors, based on study data.

Process evaluation of the Disability Allowance programme in the Maldives
International Social Security Review, Vol.75, 1/2022 "If they [the health worker] were doing the [functional] assessment … if the person is someone they know or are related to … and if the decision here is based on what that assessment says, they don't want to take that risk in case people know that it was based on their assessment … they say they wouldn't be able to live on that island anymore" (NSPA implementer).
Specialist health professionals.These actors play a critical role for the application process by enabling the medical certification of a particular condition or impairment, or of a "medical need" for assistive devices.The scarcity of health professionals who can provide this documentation creates a significant bottleneck in the delivery of the Disability Allowance.Health Centre staff on islands cannot perform this role as they are general physicians (GPs) and health workers who are not authorized to provide diagnoses beyond certain very common conditions.Applicants may thus have to travel to a Regional Hospital, but again without any guarantee that a relevant specialist will be available and where appropriate facilities for tests, scans and other diagnostic services may not be in place.As such, there was consensus among interviewees that, in practice, most people will choose to come to Malé because of the availability of relevant specialists and equipment, as well as a perception that facilities and doctors are of a higher quality andimportantlythat the recommendations of the latter are more likely to be accepted by the NSPA.
"So what happens is … we need to go to Malé to get the doctor's certificate … Health Centre certificates are not accepted, Atoll Hospital's [certificates are] not accepted, Regional Hospital's [certificates are] not accepted.We need to consult people at [the tertiary hospital] in Malé, someone on a committee and that person has to say "Oh yes, this person is missing one leg" (Island Council official).

What is delivered?
Having examined the design of the Disability Allowance and how it is delivered, in this section we assess the implementation, including the extent to which the Disability Allowance is being delivered as planned.Table 2 summarizes the different domains of analysis and related factors.
Benefit level.The Disability Allowance is MVR 2,000 (approx.USD 130), as specified in the Disability Act (article 26 (a)) (Government of Maldives, 2010),

Process evaluation of the Disability Allowance programme in the Maldives
provided on a monthly basis directly into authorized bank accounts (either the disabled person's bank account or that of their parent or guardian).In-depth analysis of the benefit level and its impact are taken into account in the wider impact evaluation within which this process evaluation is set.This process evaluation revealed inhibiting factors that have to be addressed to improve outcomes.
Beneficiaries resident in islands without an ATM or other cash withdrawal facilities 8 have to travel to the nearest major island with a facility to withdraw the cash or wait until the "Dhoni Bank" 9 operated by the Bank of Maldives visits their island.This service appears to function well, although there were some difficulties noted by beneficiaries where, for example, they were unaware the Dhoni Bank was visiting and missed the opportunity, so had to wait a further month to receive money.For people who depend heavily on the Disability Allowance, even slight delays in accessing the cash transfer could cause difficulties, such as by creating delays in paying utility bills.
Some beneficiaries also reported problems in accessing payments due to difficulties in setting up a bank account or in withdrawing funds on islands that are more geographically remote.
8. The Bank of Maldives offers cash withdrawal facilities in some shops through a Point of Sale (POS) facility, although only one beneficiary mentioned knowledge of this service.9.A banking service provided for islands without ATMs, where a dhoni (a boat) visits islands monthly to provide needed banking services.Disability Allowance payments can be sent to a beneficiary's legal guardian.However, there is a lack of clarity on when to allow a representative to act on behalf of the beneficiary, and no monitoring of how the money is spent when it is given to a non-beneficiary.A number of respondents raised this issue, particularly among non-governmental organizations (NGOs), who felt that some kind of system should be put in place to ensure the benefits are "going to the right place and to the right person and being spent on the right person".
Reach.At the start of the process evaluation in June 2016, NSPA records showed 6,839 beneficiaries receiving the Disability Allowance, making up 1.7 per cent of the population of the Maldives.Of these, 3,922 (57 per cent) were male and 2,917 (43 per cent) were female.Half of the participants (50 per cent) were aged 30 or younger.Approximately 11 per cent of the participants were aged 65 or older.The age distribution of participants was similar between men and women.Table 3 shows the Disability Allowance enrolment by year, since the programme's introduction in 2011.
On average, the NSPA receives 50 to 65 applications per month for the Allowance and 50 to 60 applications per day for Medical Welfare.In the latter case, only a smaller sub-set of these applications is either for assistive devices or for medicines for people with disabilities.It is clear from Table 4 that only a small proportion of people newly enrolled in the Disability Allowance receive assistive devices each year.
It is highly likely that the Disability Allowance is not reaching all eligible individuals.Even the most conservative estimates of national disability prevalence (4 per cent from the Maldives Demographic and Health Survey) (Ministry of Health and Inner City Fund, 2018) suggest coverage of the Disability Allowance Source: Administrative data provided by programme implementers (NSPA).

Process evaluation of the Disability Allowance programme in the Maldives
would not exceed 50 per cent of those who should be eligible.Further, half the Disability Allowance recipients are aged 30 or younger.However, disability prevalence in the Maldives, as is the case globally, increases rapidly with age (Ministry of Health and Inner City Fund, 2018;WHO and World Bank, 2011).
Consequently, there are likely to be high coverage gaps amongst older adults with disabilities.
It is therefore clear that programme reach is not complete, particularly given the large volume of applications received and screened every month.The process evaluation identified several elements affecting this reach.
• Limited recruitment activities.The NSPA does not actively encourage applicants to apply and only engages in limited activities to publicize the Disability Allowance or Medical Welfare.Advocacy and communication on disability issues are formally the role of the Ministry of Gender, and NSPA staff felt that the primary means of recruitment was likely to be by word of mouth within the community.
• Eligibility unclear.All Maldivian citizens who are deemed to have a disability, as determined through medical and functional assessments, are eligible to receive the Disability Allowance.Income is not a factor in the eligibility criteria.However, at the time of data collection, this information was not publicly available.A number of intervieweesespecially among NGOscited the lack of clearly communicated eligibility criteria as both a barrier for entry to the programme and a cause of dissatisfaction among those whose applications are unsuccessful.Because of this, there is a clash, and they raise it very negatively about how the government treats people with disabilities, because NSPA is government" (Key Informant from NGO).
Application difficulties.The Disability Allowance is implemented nationally without specific adaptation to different settings.There is, nonetheless, a recognition that the application process for the Disability Allowance and Medical Welfare of people with disabilities in Malé and on nearby Atolls will be different from those on more remote islands.For example, for those who need to travel to Malé to register, the application process can be expensive.They will need to cover the costs of travel, accommodation and food for themselves and anyone assisting them as well as for the medical assessment in some cases.An Island Council official explained it would not be unusual for families to spend upwards of MVR 15,000 (approx.USD 950) for costs associated with travel to and staying in Malé during the application process, which is equivalent to "about 8 months of this child's [Disability Allowance] money".These upfront costs are prohibitive for many families.NSPA has put in place several processes to address the additional challenges faced by island-based applicants: applications for the Allowance can be submitted through Island Councils rather than directly to the NSPA office in Malé, and Medical Welfare can be used to cover the costs of the application (i.e. the medical assessment, report and associated travel costs).However, there appears to be incomplete awareness of these processes outside of the NSPA.For example, the perception that forms should be submitted directly to the NSPA was widespread among beneficiaries on the islands and few beneficiaries were aware that Medical Welfare could cover application costs.
Adaptation.Process evaluations aim to capture alterations made to interventions to achieve better contextual fit (Moore et al., 2015).In this regard, two notable adaptations were made to the Disability Allowance during this evaluation.First, to help address communication difficulties, the application process was modified to include automated text messages being sent to applicants informing them of receipt of their application, and of approval or rejection.
Second, the post-application processes within the NSPA were revised so that decisions are made by committees, reducing the risk of personal biases in decision-making.
There are instances of evident adaptations beyond the evaluation period, indicating the NSPA's commitment to the Disability Allowance's delivery.These include functional assessments being made in-person where the applicant has an impairment that makes travel difficult, and sending the Disability Allowance cash benefit to a nominated bank account, which may be helpful for some recipients (e.g.those with severe intellectual disabilities).The NSPA website shows evidence of improved dissemination of vital information, such as verifying that applications may be submitted to Island Councils so that applicants do not have to travel to Malé, and a pledge to notify applicants of a decision within 15 working days of application. 10Crucially, in 2019, the NSPA published eligibility criteria for the Disability Allowance, addressing issues related to unclear eligibility.
Fidelity.An assessment of fidelity seeks to verify whether implementation has occurred as planned.Several factors that contribute to this domain have been discussed above and are summarized here.
• Inconsistent practice among actors.The varied and limited training provided to NSPA staff leads to variation in how applicants are assessed.The information gaps among and between Island Councils mean that island-based applicants are not receiving assistance as intended.Consequently, application decisions may be inconsistent, leading to exclusion and inclusion errors.
• Lack of a written protocol to guide key decisions.This makes it difficult to verify adherence to what was planned, limits accountability and transparency, and ultimately detracts from the integrity of the programme.There is inadequate recognition that each decision creates repercussions for the applicant.For example, requiring an in-person verification for an island-based applicant might lead to high transport expenses.Similarly, rejection of an application as a result of an error in the internal process may lead to a loss of faith in the programme and discourage applicants.
• Lack of a formal connection between Disability Allowance and Medical Welfare programmes.This is a limiting factor that restricts programme reach as well as the anticipated outcomes of the Disability Allowance.In cases where Disability Allowance beneficiaries have an unmet need for an assistive device or medicines provided by Medical Welfare, the "Theory of Change" suggests that 10.See the NSPA website.
Process evaluation of the Disability Allowance programme in the Maldives the opportunities for positive impacts are likely to be greater if they have access to both programmes.

Context
Contextual factors are external to the intervention but may influence its implementation or moderate its impact (Moore et al., 2015).Broader factors include the geography of the countrythe Maldives have numerous remote islands, adding challenges to the Disability Allowance's delivery.For example, many application services (medical specialists, NSPA offices) are located in the capital.Moreover, the small island communities mean that it is often known who does and who does not receive the Disability Allowance, which may influence the decision to apply.Similarly, this makes decentralization more challenging as Island Councils know community members and may have close links with some, creating the possibility for biased decision-making.
Other contextual factors relate to the policy-level actors.The Ministry of Gender has overall responsibility for disability in the Maldives.This includes responsibilities such as promoting advocacy and awareness of disability, conducting outreach visits to the islands, and checking whether people are receiving the Disability Allowance.
The Ministry of Gender is mandated to establish a national Disability Registry under the 2010 Disability Act, but this is not yet in place.In its absence, the Disability Allowance beneficiary list is the only national database of people with disabilities in the Maldives, and thus plays a crucial role in emergencies (e.g. the tsunami response of 2004).This has led to the widespread misperception that the NSPA is maintaining the national disability register, which is widely criticized for being incomplete.This is despite the NSPA's insistence that their list is an application-based list of beneficiaries of a cash assistance scheme.It was evident in interviews that this had also led to a conflation of the roles of the NSPA as a financial institution and the Ministry of Gender as a welfare service provider.In 2018, the new government structure saw the NSPA subsumed under the Ministry of Gender.It remains to be seen whether this restructuring reduces the misperception of their respective institutional roles and permits greater coordination in meeting their overlapping responsibilities to persons with disabilities.
Another contextual factor affecting the implementation of the programme is related to the work of NGOs.Various NGOs work with people with disabilities and their families to provide assistance and advice regarding the Disability Allowance.For example, the Autism Association advises people about the application process and facilitates appointments with psychiatrists who can Process evaluation of the Disability Allowance programme in the Maldives provide a diagnosis and medical report.However, many have a specific focus on children, which means that adults with disabilities are less likely to receive support in applying for the Disability Allowance programme.
Finally, the data suggests that the lack of access to and availability of disability-specific services is a significant challenge.A key assumption in the "Theory of Change" is that the Disability Allowance benefit amount and the assistive devices available through the Medical Welfare programme are sufficient, provided that other disability-specific services are also available.However, most participants reported that there were significant gaps in the availability of rehabilitation services.For example, nearly all rehabilitation and therapy services are located in Malé.One key informant reported: "We cannot say that we have a proper rehabilitation programme … Special services are limited, like speech therapy" (Key Informant from Government Agency).
The ways in which these gaps moderate the impact of the Disability Allowance is a key focus of the wider impact evaluation.

Discussion
Are programme objectives and design relevant to the priorities of the target population?
The process evaluation suggests that people with disabilities in the Maldives face significant challenges in meeting the extra costs they incur as a result of their disability.Taken together, the two social protection programmesthe Disability Allowance and Medical Welfareaim to address these issues directly through cash support and the provision of appropriate assistive devices and medicines.As such, the programmes' objectives are of great relevance to the target population.
It is particularly notable that unlike most other schemes implemented by the NSPA, the Disability Allowance is not means-tested.In addition to creating a significant administrative burden, means testing focuses on the question of income in isolation, while failing to acknowledge disability-related expenditure (Gooding and Marriot, 2009).The Allowance is also non-conditional.In other words, it does not place any conditions on how the benefit is spent or require recipients to access particular services (e.g.rehabilitation services) to continue receiving benefits.Although some key informants alluded to the possible positive features of such a system, conditionality is unsuited to contexts where associated services are limited (e.g.no rehabilitation services are available in the islands) (Gooding and Marriot, 2009).
However, evidence is required concerning the actual current needs of people with disabilities enrolled in the programme.Also unknown is whether people with disabilities are currently employed and/or contributing to the household income beyond the benefit received under the programme.Data is also needed on whether the programme has positive impacts on poverty, participation and quality of life, as anticipated through the "Theory of Change".

What are the factors shaping programme delivery?
As the implementing agency, the NSPA has expressed high levels of commitment to the successful delivery of the two programmes.However, there are several factors that need to be addressed in order to strengthen this.There is ample evidence that implementers' attitudes, knowledge and practices can act as barriers to entry into social protection programmes (Goldblatt, 2009;Gooding and Marriot, 2009).Thus, strengthening training for implementers and systematizing practices among actors (e.g.Island Councils, health workers) could improve Disability Allowance delivery as well as reach.Similarly, a lack of clarity about eligibility rights has been known to affect access to social protection programmes (Goldblatt, 2009).Positively, the NSPA has published the eligibility criteria for the Disability Allowance programme in the light of the recommendations of this study, and has committed to making the criteria widely available.
The functional assessments are a critical element in the delivery of the Disability Allowance programme.Although it was beyond the scope of the process evaluation to evaluate these in depth, findings suggest that this step is pivotal to the application process and outcome.Not only are assessments based on functioning more in line with the CRPD, but they are also more practical to implement than medical protocols that require more expertise among implementing staff (Graham, Moodley and Selipsky, 2013;Devandas Aguilar, 2017).However, a lack of training, guidelines as well as transparency of functional assessments can lead to inconsistent decision-making (Banks et al., 2017).As such, required is better recognition of the significance of this disability assessment, as are improved steps taken to strengthen this process.These may include further research to assess the explicit decisions made about the approach (e.g. the medical model of assessing disability is common in social protection interventions), and to recognize and address difficulties in assessing some impairments (e.g."invisible" disabilities) based on past research (Banks et al., 2017;Gooding and Marriot, 2009).
Although it is clearly important to ensure that as many eligible beneficiaries as possible are enrolled in the programme, it must also be recognized that the Government of the Maldives is likely to have legitimate concerns about the budgetary implications of a rapid expansion of the numbers of people receiving the Disability Allowance.Ultimately, this will rely on a broadening of the fiscal space to accommodate all eligible people with disabilities, along with a concurrent strengthening of policies and protocols affecting inclusion into the programme.This could include reviewing the case for the active involvement of island-based professionals in the assessment process; reviewing and improving the functional assessment process; and developing in-job training on disability assessment for implementers and relevant stakeholders.In compliance with international standards (e.g.Article 70 of the ILO Convention on Social Security (Minimum Standards), 1952 (No. 202), a formal process for appealing decisions should be introduced alongside a more robust application process to ensure that there are appropriate checks and balances in place for applicants. 11 What are the factors inhibiting/contributing to the programme achieving its intended objectives?
A key inhibitor to achieving the programme's intended objectives is the absence of a formal link between the Disability Allowance and Medical Welfare, both of which are implemented by the NSPA.For instance, where people face significant costs to apply for the Disability Allowance, they are not currently informed that Medical Welfare support can be used to defray these costs.This is particularly relevant because, similar to findings from Nepal and Viet Nam (Banks et al., 2019b, Banks et al., 2019a), expenses associated with application (e.g.travel, medical assessment) can be barriers to entry.This lack of alignment between the programmes may reduce the impact of each.Another factor is the limited specialized health and rehabilitation services available in the Maldives, especially outside of Malé.Thus, the role and impact of the Disability Allowance in facilitating this access is a core area of interest for the wider impact evaluation.
There was consensus among interviewees that the benefits received are valued by recipients and contribute towards addressing poverty, meeting basic needs, accessing specialized health and education services andin some casespromoting investment in productive assets or other means of strengthening livelihoods.There was also recognition among many key informants that this is likely to vary geographically, especially between Malé and remote islands.There are likely to be major differences for children, adults of working age, people with more severe disabilities and older people.For the latter, they are also eligible to 11. See full text of ILO Convention No. 102 (1952).
Process evaluation of the Disability Allowance programme in the Maldives receive the Old Age Pension, with the combined amount of both benefits representing a considerable sum of money.The evidence from the impact evaluation is therefore important in demonstrating the variation in impacts geographically and demographically, which in turn will allow the programme to be improved to address the particular needs of specific groups.
There are limitations to this process evaluation.Key factors shaping the Disability Allowance, such as the validity of the functional assessments and programme inputs (budget allocation, human resource capacity), were not analysed in depth.Also, the unavailability of disability prevalence figures meant that an accurate capture of the Disability Allowance's reach was not possible.This is addressed in the wider impact evaluation that includes a population-based survey, with specific questions for Disability Allowance beneficiariesthese data will provide quantitative figures for the factors inhibiting and facilitating access to the programme.The impact evaluation will examine the sufficiency of the cash amounts (benefit level) provided to beneficiaries and how these funds are spent.The qualitative component of the impact evaluation will explore the mechanisms of impact and factors contributing to programme coverage (reach).

Conclusions
The Disability Allowance in the Maldives is a non-means tested, non-contributory social protection programme providing much needed financial support to people with disabilities.This process evaluation has highlighted several factors that have to be addressed to strengthen its design and delivery.These include better linkages with the parallel Medical Welfare scheme that provides assistive devices, as well as strengthening training among implementers, establishing written protocols to systematize implementation, and introducing formal processes for appeals and redress.A key enabling factor is the commitment demonstrated by the implementing agency, the NSPA, in addressing several issues raised during and after this study.While the impact evaluation of the Disability Allowance programme will identify important learning for improving its effectiveness, the approach and findings of this process evaluation are highly relevant to the design of other social protection programmes and disability programmes in other countries.

Figure 1 .
Figure 1.Key stages, methods and participants of the process evaluation of the Disability Allowance programme in the Maldives

Figure 2 .
Figure 2. Theory of Change for the Disability Allowance programme in the Maldives indicating elements of the programme (boxes on the left) and expected outcomes (boxes in white) . Officials from the Ministry of Finance and Treasury reported the total amount allocated to the programme increased from MVR 116 million in 2014 (USD 7.6 million), to MVR 129 million in 2015 (USD 8.4 million) and MVR 168 million in 2016 (USD 11 million) (Ministry of Finance and Treasury, 2016).

Table 1 .
Actors in the delivery of the Disability Allowance, their roles, and intervening factors

Table 2 .
Domains of implementation analysis and related factors (-) Lack of formal connection between Disability Allowance and Medical WelfareSource: Authors, based on study data.Process evaluation

of the Disability Allowance programme in the Maldives "
I send someone with my cash card to withdraw money, or I go to the bank in Malé, with someone's help.But I can't take the cash anymore, it has been 4 months now … I can't go, I can't walk … my cash card has expired and the [replacement] card was sent to the next island by mistake, I don't know" (Beneficiary).

Table 3 .
Disability Allowance enrolment by year

Table 4 .
Assistive devices provided through the Medical Welfare programme Others' include all additional assistive devices not mentioned in the Assistive Device Column, such as CPAP, BiPAP and VPAP devices, physiomesh walkers, prosthetics and oxygen concentrators.Source: Administrative data provided by programme implementers (NSPA)."Thetarget members, parents do not know what eligibility criteria is.And because they don't know … say it is someone who is mildly autistic or a minor physical disability … they might say "I've submitted the form but I don't get the allowance and they have said I don't have a disability, but I do have a disability" … they don't know what constitutes a disability here, that it is when they have an impairment and face certain challenges.