Early Intervention for Children with Hearing Impairment in the South African Context: A Narrative Review of Legislative and Policy Frameworks

Abstract

Globally, many countries have promulgated extensive, contextually relevant disability legislative policies for children with hearing impairment/d/Deafness (HI/d/D). The alignment of policies with their implementation, with robust monitoring, is essential for effective early intervention (EI) and early education (EE) outcomes. The study’s purpose was to review current South African EI and EE regulations, acts, and policies in relation to children with HI/d/D from birth to age six. An adapted Arksey and O’Malley framework with inductive thematic analysis was applied to synthesise and evaluate relevant information. Documentation was sourced between 1993 and 2023 from the official South African government portal and Google online searches using keywords. While 7976 documents were initially identified with the broad search and 1249 with a refined category search, only 17 met the specific inclusion criteria for policies referencing hearing impairment in early intervention and education. Seventeen documents were selected for study inclusion, with sixteen mentioning HI/d/D and multi-disciplinary, multi-sectoral, family-centred, culturally sensitive considerations superficially. One document from the Department of Health (DoH) specifically addressed early hearing detection and intervention (EHDI). Three main themes emerged, including Partnerships, Participation and Integration, Screening, Identification and/or Intervention, and Education/Special Education. Greater engagement with South African EI and education policies is essential to strengthen implementation, especially across sectors and at the community level. Mandating EHDI guidelines is critical to improving service delivery and ensuring smoother transitions between health, education, and social services for children with hearing impairment.

1. Introduction

The concept of disability, as defined by the World Health Organisation (WHO) [1], includes various impairments, constraints on activities, and barriers to participation and is recognised as an encompassing term in which hearing impairment (HI) is considered a sensory disability [2]. The WHO, in collaboration with the United Nations Children’s Fund (UNICEF), has declared disability to be an imperative concern of human rights [3]. Internationally, legal country-specific policies concerning disability and the rights of children have been influential in promoting the health, well-being, and engagement of children with developmental disabilities [3]. This is also the case in South Africa, with its 2007 ratification of the United Nations 2006 Convention on the Rights of Persons with Disabilities (UNCRPD) [4,5]. South Africa further aligned its policies to the WHO’s International Classification of Functioning, Disability, and Health [6] through its Department of Social Development (DSD) 2015 National Integrated Early Childhood Development Policy (NIECDP) [7] and its 2016 White Paper on the Rights of Persons with Disabilities (WPRPD) [8].

The negative effects of HI may be regarded as inherently pervasive across an individual’s lifespan. A child with congenital or acquired hearing impairment may experience a host of negative consequences on their development in areas such as language, social and emotional competency, literacy, and vocational and socio-economic prospects [9,10]. Improving the hearing-impaired individual’s quality of life and reducing the overall social burden depends on the ability of early hearing detection and intervention (EHDI) programmes to identify infants with HI as early as possible and then provide timely early intervention (EI) [11]. Across the globe, EHDI has been applied in many contexts and is considered critical to reducing the negative consequences of undetected or late detection and intervention for HI [12]. The WHO has set forth guidelines and principles aimed at mitigating the impact of HI in children, emphasising the importance of EI and inclusive education [9,10]. The success of EI initiatives, be they home, centre, or pre-school-based, is often dependent upon the legislative and policy frameworks of individual countries. Actualising fundamental policy goals, such as promoting individual and community well-being and enhanced quality of life [13,14,15], is contingent upon well-considered policy design, where country-specific contextual considerations are included.

In reference to contextual consideration, international EHDI guidelines and/or position statements, such as those by the Joint Commission on Infant Hearing (JCIH) [16,17], the Family-Centered EI Deaf/Hard-of-hearing (FCEI-DHH) international consensus panel [18], and the resident statutory Health Professions Council of South Africa (HPCSA) [19,20,21], detail specific guidance in reference to principles, benchmarks, and quality indicators as they pertain to various levels of healthcare and community contexts. It is emphasised that EHDI programmes must be contextually germane [16,17,19,20,22,23]. This acceptable tenet is even more acute in low and middle-income countries (LMICs) such as South Africa. It is within LMICs where the level of additional challenges is significant when compared to high-income countries [24]. These challenges, which are also applicable to South Africa, include endemic illnesses [25,26], poverty [26,27], and reduced resources [28].

Inherent to contextual relevance is the application of collaborative processes to ensure optimal service provision for individuals with hearing impairment. To this end, the JCIH [16,17] recognises that a high level of intra and inter-sectoral collaboration is required to ensure effective care. Such sectors include private and public healthcare and education departments at local and national levels, with state-wide systems coordination recommended [16,17]. The JCIH’s recognition [16,17] of state-wide systems management and their inherent connection to the guidelines and policies on which they are based is a step forward regarding the evaluation of guidelines and policy compliance, where non-compliance provides the catalyst for systematic change at a practical level.

With specific regard to the HPCSA and EI, HPCSA EHDI guidelines call for a collaborative effort among different departments of the South African government to support individuals with HI [20]. The HPCSA also stresses the importance of a family-oriented EI process, which should be grounded in a community-based service model that aligns with cultural values [20]. This approach is in line with the JCIH statements [16,17], as well as the Family-Centred EI for d/Deaf and Hard-of-Hearing (FCEI-D/HH) consensus panel guidelines [18], which all highlight the significance of family partnerships. Such partnerships often include cooperation among family members and professionals like audiologists, speech therapists, educators, physiotherapists, and psychologists [20]. Addressing the challenges faced in South Africa requires comprehensive effort with defined pathways that offer strategies to overcome the logistical, health, and financial obstacles commonly encountered in its low–middle-income country (LMIC) context [29,30]. The HPCSA [19,20] has attempted to do so in its EHDI guidelines, which, for best outcomes, requires firm legislation to facilitate adherence [28].

South Africa’s National Integrated ECD Policy [7,31] specifies that ECD includes EI services to cover children from birth to six years. This aligns with South Africa’s Department of Health’s developmental monitoring and screening of children birth to six years [32,33]. Age considerations are critical in the policy landscape, especially regarding inter-sectoral partnerships where HI/d/D management straddles government entities such as the Department of Health (DoH), social development, and education, and when children with HI/d/D transition between sectors. It is thus within this context that this paper is positioned, namely within the birth to six years of age cohort.

As far as policy development is concerned, South Africa, within the global context, has progressed significantly since 1994, when government plans recognised ECD as a programme of national priority, with its placement at the centre of the 2030 National Development Plan [34] (South African Government, 2012), the DSD’s Integrated Programme of Action for ECD [35], and the DSD’s National Integrated ECD Policy [7,31]. Investment in children’s early development is considered critical to facilitating improved performance in formal schooling (the year in which the South African child turns seven) [7,31], which is, in turn, recognised to result in improved employment levels [36]. However, within the South African context, service delivery has been described as having adopted a siloed approach without integration within departments and between organisations [37,38]. In addition, whilst many high-income countries (HICs) (e.g., United States of America, Canada, Australia, most Western European countries) [9] have sought to comply with the EHDI gold standards as promulgated by the JCIH [16,17,22,23], where the mandated inter-sectoral liaison is recognised as crucial to successful EI for the hearing impaired, EHDI, as mentioned, is not mandated within the South African context [29]. Without standardised processes within the South African context, where a piecemeal approach has emerged [37], checks and balances related to the efficacy of EI processes for a child with HI become difficult to measure.

International studies conducted within high-income country (HIC) and LMIC world contexts regarding factors that influence policy implementation have reflected the dynamic and holistic intricacies and challenges inherent in policy application. These include EI timing, EHDI/EI mechanisms such as data management/systems, EI logistics, and infrastructure, EI services (type and intensity), early education (EE) factors such as transition to EE settings, family considerations, and policy development and application [39,40,41,42,43,44,45,46,47,48]. Within these HIC world milieux, intersectoral collaboration for seamless transitions between government entities is well considered. An example is the United States of America’s suite of interlinking multi-sectoral laws (health, education, welfare) that direct the American child’s system trajectory dependent upon the specific disability at hand [49]. The EHDI program is entrenched within this broader USA policy landscape and federally mandated with information systems support [17,50]. In this way, all young children identified with a HI are eligible to receive required services, including the provision of hearing aids, educational resources, and speech therapy [50].

Within the South African context, a paucity of scientific data exists regarding the actual EI guidelines recommended by the HPCSA compared to South African government policy directives in relation to the holistic management of the child with HI at birth to age six. With this in mind, and on reflection of the well-considered HIC context, scrutiny of South African EI HI/d/D policy detail is required to identify opportunities for improvement in EI policy and EI application within the home-based, centre-based, and pre-school-based milieu.

The success of any intervention programme requires aligned interaction between policies and practice, with sensitive monitoring tools to allow for the efficacy and effectiveness of interventions. Policy design and application are inextricably linked where policy application success is often dependent upon its design; government policies provide structure and direction regarding often complex cross-sectional societal issues [51,52] such as EI for HI/d/D. Policies also encourage accountability and are often informed by evidence-based practice, especially within the healthcare sector [53]. Moodley [2] comments that despite South Africa’s commendable disability legislation, the long-documented policy implementation challenges persist. These challenges with implementation could result in a lack of coordinated services across the sectors involved in EHDI. It is within this context, and as part of a larger study, that this narrative review of South African government policies, as they relate to EI and EE for the child with HI from birth to age six, is located. This narrative review aims to critically analyse existing South African regulations, acts, and policies on early childhood development, early intervention, and early education as they pertain to children with HI/d/D from birth to six years in order to identify policy strengths, gaps, and opportunities for improved implementation. This is currently of particular significance in expediting the design of appropriate strategies for actualising early intervention for South African children, where delays in intervention prevail due to contextual challenges [54,55,56,57,58,59]. Despite progressive legislation and recognition of early intervention principles, a key disconnect remains between policy ideals and their practical implementation—particularly in the absence of mandated EHDI guidelines, standardised procedures, and coordinated delivery across sectors.

2. Materials and Methods

A narrative review was selected as the most appropriate approach for this study due to the diversity and heterogeneity of the South African government policies and regulations across sectors such as health, education, and social development. Unlike systematic reviews, which are more suited to focused clinical or intervention-based questions, a narrative review allows for a broader, interpretive synthesis of policy documents, enabling the exploration of thematic patterns, contextual relevance, and policy alignment. This approach is particularly useful for examining complex, multi-sectoral policy environments such as EHDI, where the interplay of frameworks, mandates, and implementation varies significantly across documents and departments.

2.1. Structure and Reporting

To enhance study rigour, an adapted Arksey and O’Malley framework [60] was applied during the document access, screening, and data charting. Arksey and O’Malley’s adaptations were required by predetermining document inclusion/exclusion criteria with data charting ensuing accordingly, navigating different data formats (policy documents in place of studies), and evaluating their content lists. Data synthesis and descriptive qualitative analysis included inductive thematic analysis of pertinent information extracted [61].

2.2. Identifying Relevant Documentation; Inclusion/Exclusion Criteria

Documents were sourced between May 1993 and May 2023. This timeframe is reflective of South Africa’s new, non-Apartheid dispensation period. This timeframe was also selected as even though the regulatory body tasked with guiding the health professions and protecting the public [20], the HPCSA, first introduced its EHDI guidelines in 2007 [19], legislation prior to 2007 may still be applicable.

The official government portal, www.gov.za, was used to access relevant national documentation from which all other provincial and local-level policies are generated. In addition, Google online searches were used to cross-reference and assist with locating relevant grey literature.

Non-formalised documentation and items, such as speeches and discussion papers, as well as annual departmental reports, were excluded. The following conceptual keywords, with associated variants listed in brackets, were used for highest yield pertaining to reference of hearing ability/disability: early childhood development; early intervention (early childhood intervention); early hearing detection (and intervention); disability (disabilities/disabled), sensory (sensory impairment/loss); deaf (deafness); hearing (hard-of-hearing/hearing impairment/hearing loss/hearing impaired; hearing screening); special needs (special/inclusive education); basic education; audio (audiology/audiometry/audiometric). Initially, search categories were not refined in order to reach the maximum yield. This approach, depicted in Figure 1, resulted in 7976 documents identified, with the majority being inappropriate. The excluded documents included those not related to disability and ECD (inclusive of EI and EE) for children with HI/d/D from birth to age six. These included documents pertaining to the Gender-Based Violence and Femicide Declaration, tender bulletins, waste management items, International Air Services Act documentation, Probation Services Amendment Bill, Fire Brigade Services Amendment Bill, and the like. Refinement of the search process was thus deemed necessary to target particular areas within the review’s desired scope. To improve search compatibility with the government website’s filtering system, the categories selected were guided by the website’s available dropdown menu tool. Here, eleven categories were selected as per the following: Children, Gender, Women, Youth, and People with Disabilities; Constitutional Issues; Education—ECD; Education—Departmental Reports; Education Schools; Health—Departmental Reports; Health—Public Health; Human Rights; Local Government; Provincial Government; Social Development. Document inclusion criteria incorporated specific references to disability, with further refinement referencing HI/d/D. This refinement resulted in a total of 1249 documents detected, 93 duplicates removed, 1139 documents excluded, and 17 included for qualitative synthesis. This is depicted in the flow diagram below.

2.3. Data Charting and Synthesis

A structured data charting process was used to extract and synthesise information from each included document. The final sample of 17 records was reviewed systematically, charted as per the study objective, according to year of issue, government sector, and document title, with verbatim text in reference to EI HI/d/D children extracted and page numbering and context detailed [60]. Key data categories included the following: (i) document title, (ii) year of publication, (iii) issuing department, (iv) target population, (v) references to hearing impairment, deafness, or Deaf identity (HI/d/D), (vi) references to early intervention (EI), early education (EE), and early childhood development (ECD), (vii) sectoral responsibilities, and (viii) implementation mechanisms or gaps. The first author extracted data into the framework, with the rest of the team independently verifying the data to ensure consistency and mitigate bias. Where discrepancies occurred, they were resolved through discussion and consensus. Once charted, data were organised thematically using an iterative process. Verbatim texts were then qualitatively synthesised [60] with the use of inductive thematic analysis [61] to determine key themes and trends within and across documents. Inductive thematic analysis was applied according to Braun and Clarke’s six-phase framework [61]. The process included data familiarisation, generating codes, deriving themes, reviewing themes, defining and naming themes, and generating a report. The validation of themes involved reviewing and refining them, conducting ongoing analyses, and utilising researcher reflexivity. The first author initiated the coding process by highlighting significant charted text segments. Subsequent steps involved reviewing the codes, identifying patterns, and consolidating related codes into themes. Themes were developed inductively from the content of the policy documents rather than imposed a priori. Quotes were used sparingly and only where they illustrated significant policy gaps or thematic patterns. The final synthesis considered cross-sectoral alignment, specificity to HI/d/D, and the presence or absence of implementation guidance. As the documentation was located within the public domain, there were no direct methodological ethical considerations to deliberate.

3. Results

Seventeen documents published between 1993 and 2023 met the inclusion criteria and were analysed to explore how South African policies address early intervention (EI) and early education (EE) for children with HI/d/D aged birth to six years. These documents and their scope regarding the study’s objective are reflected, per document, in Table S1 (Supplement Materials), with inductive thematic analysis applied [61]. Three themes and four sub-themes were detected, with theme/sub-theme in-document details also provided in parentheses within Table S1.

3.1. Overview of Included Studies

Results detailed in Table S1 are reflective of the chronological evolution of disability policy in reference to EI for children with HI/d/D from birth to age six. Of the 17 documents considered relevant, 3 documents (17.65%) were located within broader/higher government (B/HG) sectors such as the presidency of South Africa, with 6 (35.29%) located within the DSD, 6 located within the Department of Education/Department of Basic Education (DoE/DBE) (35.29%), and 2 (11.77%) located within the National Department of Health/Department of Health (NdoH/DoH). While all documents acknowledged disability more broadly, only a few explicitly addressed HI/d/D, and often only in passing. This reflects a policy landscape that recognises inclusivity in principle but lacks consistent attention to the specific needs of children with HI/d/D.

3.2. Themes

On application of inductive thematic analysis [61], three main emergent themes were derived in reference to detail and the overall context in which the detail was expressed. These three main themes included Partnerships, Participation, and Integration within 14 of the documents (N = 17; 82.35%; B/HG n = 2; DSD n = 5; DBE n = 5; DoH n = 2), Screening, Identification and/or Intervention within 7 of the documents (N = 17; 41.18%; B/HG n = 2; DSD n = 1; DBE n = 3; DoH n = 1), and Education/Special Education within 14 of the 17 documents (N = 17; 82.35%; B/HG n = 2; DSD n = 6; DBE n = 6). The main themes straddled three government sectors, namely B/HG entities, the DSD, and the DBE, with no mention of Education/Special Education within the DoH. Partnerships, Participation, and Integration were the only main themes where sub-themes were derived, which included Self-Representation, Reliance and Empowerment, Collaboration, Public Awareness, and Access/Capacity/Resources. These sub-themes are also depicted within Table S1. Of note is the predominance of the sub-theme Access/Capacity/Resources (A/C/R), which reflects document emphasis on the need or provision of the following:

• Deaf culture and South African Sign Language (SASL) recognition with an interpreter, note captioning, sub-texting services, and parent and teacher training with human resource support for HI/d/D special needs.
• Funding for the above as well as resource centres as necessary, conditional grants, hearing aid provision, transport, social, health and therapeutic services, with transport to access services.

Despite this categorisation of themes, most of the HI/d/D details were essentially superficial, with interspersed HI/d/D references. The in-table (Table S1) theme details provide the relevant information in a concise format. A bid to effectively facilitate impactful recommendations, policy detail analysis, and synthesis within the 17 documents is presented below:

• Government sectors (B/HG); DSD, DoE/DBE; DoH) to identify the specific government sector stance to enable intra and interectoral analysis.
• Synthesis of themes across government sectors, aimed at providing integrated reflection on overall findings.

This approach was considered to better reflect micro and macro-analysis and synthesis regarding policy for children with HI/d/D age six and below within the South African context. Within the analysis and synthesis, relevant document excerpts (with themes/sub-themes in parentheses) are provided for further insight into specific HI/d/D detail expressed.

3.3. B/HG

Within the context of higher government entities, as a first point of reference, the Integrated National Disability Strategy White Paper [62], in its bid to equalise opportunities for those with disabilities, acknowledges the importance of EI within the context of ECD, with additional reference to the use of hearing aids and special education for d/Deaf learners. In addition, SASL is recognised as a natural and first language of the d/Deaf. It makes mention of specific EI and ECD deliberations for the Deaf child with its specific acknowledgement that the Deaf community’s stance on a deaf child’s full integration into “a hearing classroom, even with the help of an interpreter, as restrictive” (p. 59), (Theme 1, Partnership, Participation and Integration (Sub-themes Self-representation, Reliance, and Empowerment)). The following are the additional key points mentioned and reflected verbatim:

• “Although the overall policy recommendation is for the inclusion of children with disabilities in mainstream education, the Deaf community believes that Deaf children need special schools, claiming that this is of cardinal importance for their concept and learning acquisition” (p. 18, Theme 3 Education/Special Education).
• “The Deaf community argues for a special focus on the Deaf child from the age of 0–3 born of hearing parents” (p. 59, Theme 2 Screening, Identification and/or Intervention).
• “The Deaf community argues that, in the case of Deaf children, ECD and stimulation should include Sign Language instruction and the training of parents in Sign Language to enhance parent child communication, relationships, and education” (p. 59, Theme 1 Partnership, Participation, and Integration (subtheme: Self-representation, Reliance, and Empowerment)).
• “The Deaf community argues that, in most cases, compulsory education for children with disabilities should start at the age of 3 or 4 years to compensate for delays in language, cognitive, physical, emotional and social development” (p. 59, Theme 3: Education/Special Education).

In addition, the Integrated National Disability Strategy White Paper [62] refers to the importance of “screening, early identification, and intervention services, e.g., at-risk babies” (p. 57, Theme 2: Screening, Identification and/or Intervention), but this reference is generic with no specifics regarding HI/d/D mentioned. However, the importance of hearing aids is mentioned through “NGOs making devices available on temporary loan and coordinating the redistribution of devices through banks (e.g., hearing aids, etc.)” (p. 57, Theme 1: Partnership, Participation, and Integration (subtheme: Access/Resources/Funding)).

Through South Africa’s ratification of the UNCRPD (Optional Protocol) [4,5], EI is recognised as a vital pathway for those with a disability to self-actualise, inclusive of children with HI/d/D, with inclusion in education systems by “Facilitating the learning of sign language and the promotion of the linguistic identity of the deaf community” and “Ensuring that the education of persons, and in particular children, who are blind, deaf, or deaf–blind, is delivered in the most appropriate languages and modes and means of communication for the individual, and in environments which maximise academic and social development” (p. 17, Theme 1: Partnership, Participation, and Integration (Sub-themes: Self-representation, Reliance, and Empowerment, Access/Capacity/Resources); Theme 3: Education/Special Education).

Through the National Planning Commission’s Disability Background Paper: The Status of Disability in South Africa [63], South Africa’s progress in the disability legislation, policy, and administration frameworks arena was recognised with mention of hearing impairment and the application of hearing aids. Hearing screening, rehabilitation, and intervention (Theme 2: Screening/Identification and/or Intervention) were also detailed as per the following excerpts, p. 15:

• “School Setting screening as set out in the Integrated School Health Programme: Vision, Hearing, Speech and Language and Physical (gross and fine motor) makes referrals to specific hospital-based rehabilitation services”.
• “Home setting includes services such as screening, assessing and treating people with different impairments; physical, emotional, speech, hearing, communication, and visual impairments”.
• “Primary Health Care (PHC) Facilities such as clinics and community health centres (CHCs) include services such as screening, assessing and treating people with different impairments like physical, emotional, speech, hearing, communication and visual and training of community health workers on disability issues to empower them to ensure early detection of disability and referral to the right place”.
• “Hospital-based services and rehabilitation services in hospitals cover the following areas: assessment and management of patients, treatment by a multi-disciplinary team, referral, vocational rehabilitation, early hearing detection and intervention, and referral for diagnostic procedures at other and specialised services. The team at this level of rehabilitation can endorse and provide a wide scope of assistive devices”.

3.4. The DSD

Within the DSD context specifically, the DSD has applied itself to ECD policy development, where EI for HI/d/D is reflected, albeit also somewhat superficially. In its White Paper for Social Welfare [64], the d/Deaf are considered as “particularly vulnerable” (p. 75) with special needs and human resource planning and development reflected to facilitate the integration of the d/Deaf child into mainstream schooling. This is revealed in its wording, “The Department of Welfare will advocate appropriate training for teachers in order to accommodate children with disabilities and special needs in mainstream education. Human resource development and planning must consider the need for training in appropriate communication with deaf and blind people” (p. 76, Theme 1: Partnership, Participation, and Integration (Sub-theme Access/Capacity/Resources); Theme 3: Education/Special Education). In addition, the DSD’s Guidelines for ECD Services [65] emphasise the importance of early opportunities for learning, and HI is included as a disability example. Specifically, SASL is recognised and encouraged, with the need for special and mainstream education for children with HI/d/D recognised. This is reflected in the following, “Children who are deaf should not be forced to learn a spoken language, but sign language should be encouraged” (p. 44 and repeated verbatim on p. 53, Theme 1: Partnership, Participation, and Integration (Sub-themes: Self-reliance and Empowerment; Access/Capacity/Resources); Theme 3: Education/Special Education). The right to sign language is also explicitly expressed on page 81. Furthermore (p. 81), “Children with disabilities:… Have a right to inclusion, integration, and mainstream facilities and services (Theme 1: Partnership, Participation, and Integration (Sub-themes: Self-representation, Reliance, and Empowerment; Access/Capacity/Resources); Theme 3: Education/Special Education); “Children with disabilities…Have rights to devices that assist them when they need them” (Theme 1: Partnership, Participation, and Integration (Sub-theme: Access/Capacity/Resources)); and “Children with disabilities… Have a right to appropriate active learning that is suitable for their abilities without them being isolated” (Theme 1: Partnership, Participation, and Integration; Theme 3: Education/Special Education). The d/Deaf child’s right to sign language is also explicitly expressed.

Of importance is the DSD’s Integrated National Strategy on Support Services to Children with Disabilities [66], with its emphasis on mainstreaming support services for children with disabilities. It reflects consideration of EI for children with HI/d/D with specific mention of hearing aid provision and special education versus mainstreaming with teacher knowledge of SASL, sign language interpreter availability, and the availability of early screening, identification, and intervention services in special and mainstream education settings. In addition, HI classification (mild through severe) is provided. Early identification in ECD centres, as well as in special and mainstream schools, is emphasised. HI/d/D diagnostic criteria are outlined with EI services highlighted, including access to hearing aids, audiological therapeutic services, transportation, and infrastructure considerations, such as electricity to support those with severe HI. Additionally, the availability of sign language interpreters and the option for learning through either oral language or SASL are also mentioned.

The DSD’s White Paper on the Rights of Persons with Disabilities [8] promulgates primary healthcare (PHC) EI with free access to hearing aids and rehabilitation to children birth to age six, with appropriate communication modes and languages (inclusive of SASL and supports) to facilitate maximal social and academic development. Trans-sectoral intervention is acknowledged as key. The following excerpts are reflective of these aspects:

• “…Persons with disabilities are entitled, on an equal basis with others, to recognition and support of their specific cultural and linguistic identity, including sign languages and Deaf culture” (p. 50, Theme 1: Partnership, Participation, and Integration (Sub-theme Access/Capacity/Resources)).
• “Deaf persons use South African Sign Language as their first language and therefore require that they have access to SASL training, in particular for Deaf children and their parents. They require access to SASL interpreters, as well as note-takers, captioning, and sub-texting to facilitate access to information and communication” (p. 55, Theme 1: Partnership, Participation, and Integration (Sub-theme Access/Capacity/Resources)).
• “Ensuring that the education of persons, and in particular children, who are blind, deaf, hearing impaired, non-speaking autistic or deaf–blind is delivered in the most appropriate languages and modes and means of communication for the individual, and in environments which maximise academic and social development” (p. 84, Theme 3: Education/Special Education).
• “Employing teachers, including teachers with disabilities, who are qualified in South African Sign Language and/or Braille, and to train professionals and staff who work at all levels of education. Such training shall incorporate disability awareness and the use of appropriate augmentative and alternative modes, means and formats of communication, educational techniques and materials to support persons with disabilities” (p. 84, Theme 1: Partnership, Participation, and Integration (Sub-theme Access/Capacity/Resources); Theme 3: Education/Special Education).

The associated White Paper on the Rights of Persons with Disabilities Implementation Matrix 2015–2030 [67] relates directly to the WPRPD as a term of operationalisation. However, EI for HI/d/D details are still broad-based and have little actionable detail.

South Africa’s National Plan of Action for Children (NPAC) 2019–2024 [68] provides a broad-based approach to children’s rights, inclusive of non-discrimination, development, and active participation. It aims to foster an inclusive society that appreciates the unique qualities and capabilities of each child. The plan includes provisions for HI, detailing EI within the framework of social development and diversity inclusion. This is exemplified in the following excerpt, “accommodations that will enable children with disabilities, including children with intellectual disabilities, autism and deaf or hard of hearing, to receive inclusive and quality education” (p. 205, Theme 3: Education/Special Education).

Within the above, EI for HI/d/D details, although at times acknowledged, appear superficial with little relation to accepted specific EI detailed guidelines, such as those provided by the HPCSA (2007; 2018) [19,20].

3.5. DoE/DBE

Within the DoE/DBE context specifically, the DoE/DBE has applied itself to ECD policy development, where EI for HI/d/D is reflected within the context of special and mainstream education, with curriculum and language accommodations for children with HI/d/D six years and below.

Specifically, Education White Paper 6 Special Needs Education, Building an Inclusive Education and Training System [69], in its HI/d/D considerations, refers to distinct support with the consideration of early hearing assessments for the identification of HI and access to hearing aids and learning environments conducive to those with HI. This is reflected by the following excerpt, “The Ministry fully appreciates the importance of assessment and interventions during the early phases of life. It is during the pre-school years that hearing and vision testing programmes should reveal early organic impairments that are barriers to learning. Community-based clinics are in the best position to conduct an initial assessment and plan a suitable course of action in conjunction with parents and personnel from various social services such as education” (pp. 35–36; Theme 1: Partnership, Participation, and Integration (Sub-Themes Collaboration; Access/Capacity/Resources); Theme 2: Screening, Identification, and/or Intervention; Theme 3: Education/Special Education). The theme Partnership, Participation, and Integration (Sub-theme Access/Capacity/Resources) and the theme Education/Special Education is represented by the following (p. 55), “Full-service’ schools should be designated in each district for the implementation of the inclusion model, especially since it is unimaginable how all 29,000 public schools could all provide the full range of physical and material resources required—e.g., Braille writers, voice synthesisers, Hearing aids and adapted information and communications technologies—and the staff to accommodate the full range of diverse learning needs”. The document also refers to public awareness (p. 30, Theme Partnership, Participation, and Integration (Sub-themes Collaboration; Public Awareness)) by stating, ”The Ministry will put in place a public education programme to inform and educate parents of these children and youth, and will collaborate with the Department of Social Development to develop a programme to support their special welfare needs, including the provision of devices such as wheel chairs and hearing aids”.

The DBE’s 2008 National Strategy on Screening, Identification, Assessment, and Support (SIAS) [70] provided the platform for the 2014 Policy on SIAS [71]. Both aim to foster an inclusive education system by standardising how learners with barriers to learning are identified, assessed, and supported. The 2014 policy expands on the 2008 strategy, offering more detailed guidelines to ensure all learners receive the necessary support for better inclusion and participation in schools. Specifically, the strategy aims to ensure the identification and intervention of HI from grade R (reception phase) upwards. Details pertaining to children with HI/d/D are included as a domain of specialised support, with a high level of support eligibility described as those who require assistive technology or specialised teacher training of higher frequency and intensity. Diagnostic HI/d/D descriptors are provided. Within the National Strategy Screening, Identification, Assessment, and Support document [70], themes pertaining to Partnership, Participation, and Integration (Sub-theme Access/Capacity/Resources), and the theme Education/Special Education (pp. 18–19) are evident within the following excerpts, “Some special schools, especially those for learners with specific disabilities such as blindness or visual impairment, deafness or hearing impairment, or physical disability, are equipped with technical equipment such as apparatus to assess hearing loss, conduct early physical and sensory stimulation, or assistive devices…”. A practical directive under “Areas of Support” is also made by reference to “Educator or educator assistant checks batteries, ensuring equipment such as hearing aids, FM systems, or loop systems is in working order” (p. 73, Theme 1: Partnership, Participation, and Integration (Sub-theme Access/Capacity/Resources)). Within the 2014 policy expansion (Policy on SIAS and Support) [71], greater alignment between various departments, such as the DoH and DSD, is emphasised, with the category of hearing disability with specific supports recognised.

The DBEs Curriculum and Assessments Policy Statements (CAPS) Grade R-12 Guidelines for Responding to Learner Diversity in the Classroom [72] aimed at maximising a child’s potential, with broad listening assessment guidelines mentioned with referrals to specialists if potential hearing problems are detected. The theme of Education/Special Education is exemplified in the excerpt, “In a large class, a hearing impaired child or those who struggle to concentrate may experience barriers to learning because of noise levels and seating arrangements. The teacher would have to observe and adapt the curriculum to suit the needs of this learner” (p. 7). Relatedly, The National Policy Pertaining to the programme and Promotion Requirements of the National Curriculum Statement (2011, with amendments through 2015) [73] expresses support for inclusive education with learning facilitation through sign language and the use of assistive devices as necessary; mainstream or special education is offered, with accommodations in achievement levels and criteria made.

The DBEs South African National Curriculum Framework for Children from Birth to Four (NCF) [74] provides guidelines regarding early childhood learning and development inclusive of hearing as an integral part of the developmental process (Theme 3: Education/Special Education). This is expressed as the following, “The NCF provides guidance on how to develop a curriculum appropriate for babies and young children. A curriculum for early childhood is about all the experiences that children from birth to four will have in different settings. What children feel, do, hear, and see in their early childhood setting is an important part of the curriculum.” (p. 2). Broad examples to foster the child’s development through hearing are provided, with watchpoints to broadly screen hearing difficulties. Within this document’s glossary (p. 78, Theme 2: Screening, Identification, and/or Intervention), “early identification and intervention of barriers to learning, development and participation” is defined as “screening and other approaches to identify early the signs of a challenge in any aspect of child development. Early intervention is the action taken to address identified barriers to learning and development and includes all the inter-sectoral services available to support the child and her family”. The NCF acknowledges that the child who experiences difficulty hearing may experience communication barriers to learning compounded by aspects such as background noise.

Within the above, EI HI/d/D details, although at times recognised, appear cursory again with little to no relation to EI guidelines such as those recommended by the HPCSA (2007; 2018) [19,20].

3.6. DoH

Within the DoH context specifically, the DoH has applied itself to ECD policy development where EI for HI/d/D is reflected. The Strategic Priorities for the National Health System 2004–2009 [75], aimed at improving quality healthcare, details intervention planning for the improvement of key family practices that impinge on child health. The provision of hearing aids was specifically mentioned as follows, “To reduce the impact of disabilities, in particular those in need of hearing aids and wheelchairs, more than 20,000 wheelchairs and 10,000 hearing aids were distributed during this period” (p. 10, Theme 1: Partnership, Participation, and Integration (Sub-theme: Access/Capacity/Resources)).

The Framework and Strategy for Disability and Rehabilitation Services in South Africa 2015–2020 [76] reflects the DoH’s aim at boosting access to rehabilitation services. EHDI principles and timelines are specified in brief, according to international benchmarks of 1:3:6 [16,17] rather than local benchmarks [19,20], with EI applications such as hearing aid provision and audiological rehabilitative services; inter-sectoral collaboration is acknowledged as integral. In addition, EI for HI/d/D HPCSA benchmarks are further reflected by considering different settings such as home, community, and health. These aspects are reflected in the following excerpts, which are extensive in comparison to the other documents within this review:

Under “Home/Community Setting” (p. 14, Theme 1: Partnership, Participation, and Integration (Sub-theme Access/Capacity/Resources)):

“Screening, assessing and treating people with different impairments; physical, emotional, speech, hearing, communication and visual impairments. Orientation and mobility services should be part of the service package offered at this level.”

Under “School Setting” (p. 15, Theme 2: Screening, Identification, and/or Intervention):

“Screening as set out in the Integrated School Health Programme:

• Vision;
• Hearing;
• Speech and language;
• Physical (gross and fine motor)”.

Under “Hospital-Based Services” (p. 15, Theme 2: Screening, Identification, and/or Intervention):

• “Rehabilitation services in hospitals will cover the following areas:

  (a)

  Early hearing detection and intervention and upward referral for diagnostic procedures at other specialised services”.

Under “Appendix A: Glossary…Core professional rehabilitation service providers and description of Roles” (p. 20, Theme 1: Partnership, Participation, and Integration (Sub-theme: Access/Capacity/Resources); Theme 2: Screening, Identification, and/or Intervention), the role of audiologists is specifically mentioned with the following role description, “Evaluating and determining the range, nature, and degree of people’s hearing function in relation to their auditory efficiency and communication needs, including observation, the use of electro-acoustic instrumentation, and assessing receptive and expressive speech and language pathologies associated with hearing impairment. The planning, conducting, or directing of or participating in the habilitation and/or rehabilitation of people with hearing pathologies, including the fitting and use of hearing aids, auditory training, speech reading, signing systems, speech conservation, speech and language acquisition, counselling and guidance related to the hearing impairment and to hearing conservation programmes”.

Under “Appendix A: Glossary…Assistive Technology” (p. 21, Theme 1: Partnership, Participation, and Integration (Sub-theme Access/Capacity/Resources); Theme 2: Screening, Identification, and/or Intervention) hearing aids are specifically described and mentioned as follows, “Assistive technology includes assistive devices (ADs) (such as mobility devices, orthotics, prosthetics) through to communication devices (hearing aids, as well as augmentative and alternative communication…)”.

Under “Primary Health Care Facilities (clinics, community health centres)” (p. 15, Theme 2: Screening, Identification and/or Intervention):

• “5.3.1 Screening, assessing, and treating people with different impairments—physical, emotional, speech, hearing, communication, and visual”.
• “5.3.13 Providing early hearing detection and intervention in post-natal and well-baby clinics”.

In addition to a comprehensive definition of HI/d/D, EHDI is not only referred to but described as (under Appendix A: Glossary, p. 22, Theme 2: Screening, Identification, and/or Intervention), “[EHDI] Aims to ensure hearing screening by the age of one month, diagnosis of hearing impairment by the age of three months and intervention services (optimal amplification as well as family-based early communication intervention) by the age of six months. Infants who receive early intervention within the first six to nine months of life show significantly better outcomes in speech and language of development—potentially even comparable to their normal hearing peers”.

As is evident in the above, although some of the DoH’s concepts are presented within a document appendix, the details of EI for HI/d/D are better expressed with specific reference to international JCIH benchmarks and timelines. Although JCIH guidelines are the reference, which is admirable in its ideals, given South Africa’s specific contextual challenges such as logistical, resource, financial, and quadruple burden of disease constraints [29], the JCIH guideline reference may be inappropriate in application.

3.7. Theme Synthesis Across Government Sectors

3.7.1. Partnerships, Participation, and Integration

A recurring theme across most documents (82.35%) was the emphasis on inclusive participation and intersectoral collaboration. Policies often called for integration between health, education, and social development sectors but provided little detail on how collaboration should be operationalised. For example, while some documents encouraged the use of South African Sign Language (SASL) and the training of parents and teachers, they did not outline funding mechanisms, timelines, or responsibilities for service delivery.

Sub-themes within this category included empowerment, collaboration, and access to resources. Notably, there was a consistent emphasis on resource-related challenges—such as the availability of hearing aids, transport, SASL interpreters, and accessible information. These gaps underscore the disconnect between policy intent and implementation. Despite repeated references to inclusion, the actual mechanisms for achieving access and participation for children with HI/d/D were largely absent.

3.7.2. Screening, Identification, and/or Intervention

Only 7 of the 17 documents made explicit mention of screening or early hearing intervention for children with HI/d/D. The strongest references came from the DoH’s Framework and Strategy for Disability and Rehabilitation Services (2015–2020), which incorporated international EHDI benchmarks (1:3:6), described screening at various service levels (home, school, PHC), and outlined the audiologist’s role in service provision.

However, this detail was an outlier. Most documents referred vaguely to “early detection” or “at-risk babies” without specifying HI/d/D or audiology services. The Department of Education documents largely deferred screening responsibilities to health or social development sectors, further reinforcing the siloed approach noted across government. The absence of mandated screening protocols or cross-referencing of HPCSA EHDI guidelines in most documents limits the potential for coordinated early identification across settings.

3.7.3. Education and Special Education

Fourteen documents addressed aspects of special or inclusive education, with varying degrees of relevance to children with HI/d/D. The DBE’s White Paper 6 and SIAS Policy stood out for their acknowledgement of learning barriers due to hearing loss and their suggestions for hearing aid provision and curriculum adaptation. Nonetheless, most references to HI/d/D were broad and lacked practical specificity.

Significant emphasis was placed on mainstreaming learners with disabilities and supporting diversity in the classroom, yet Deaf learners’ needs were often bundled with broader categories of sensory or developmental disability. Curriculum guidance documents, for instance, mentioned environmental modifications (e.g., seating arrangements in noisy classrooms) but did not provide actionable guidance for teaching children who use SASL or require hearing technology.

3.7.4. Cross-Sector Disconnects

While each department contributed to the overall EI/EE policy landscape, a clear disconnect emerged in how responsibilities were assigned and followed through. Policies recognised the importance of collaboration and holistic care, yet few established concrete coordination mechanisms. For example, while the DSD acknowledged the need for early support and assistive devices, it did not outline pathways for service access or align its strategies with health or education frameworks. Similarly, DBE documents noted the importance of support for learners with hearing loss but did not specify referral systems or align with DoH screening practices.

This fragmentation is especially problematic in the context of the late identification of HI/d/D in South Africa. Given that many children are diagnosed only after entering early education settings, the lack of integrated processes severely limits timely intervention and support. Although some policies mentioned transition planning between sectors, few provided guidance on how to implement such transitions effectively.

4. Discussion

The current study review revealed three main emergent themes to be evident within South African policy documentation, namely Partnerships, Participation, and Integration; Screening, Identification, and/or Intervention; and Education/Special Education. The DoH’s Framework and Strategy for Disability and Rehabilitation Services in South Africa 2015–2020 [76] was the only proponent of EHDI-related JCIH guidelines, interestingly without direct reference to audiology or HI guidelines recommended by the local HPCSA [19,20]. This review highlights significant gaps, despite well-intentioned attempts, in addressing the integration of EI and EE needs of children with HI/d/D, including HPCSA EHDI guidelines, into South African policies.

In its post-Apartheid era, South Africa has progressed significantly within the world context regarding children’s rights, inclusive of disability rights, where it has declared its binding commitment on the international stage by signing the United Nation’s Convention on the Rights of the Child [77] and the United Nations Charter on the Rights of Persons with Disabilities [5]. The constitution (1993 interim) and its 1996 enactment, including its Bill of Rights, are considered well-designed and generally fit for purpose [78]. Its emphasis on equal rights and non-discrimination for all, inclusive of those with disabilities, is commendable and understandably broad-based, where the intricacies of South African society’s myriad of different disabilities cannot be expected to be included in all its heterogeneous details. Such is the case for most HI/d/D policies emanating from high-end policy structures.

The actualisation of disability rights for children with HI/d/D is generally boosted by all South African disability policies, with increased leverage powered by South Africa’s placement of ECD at the centre of the government’s 2030 National Development Plan [34]. This ratification of ECD as a programme of national priority, reinforced by the ECD Integrated Programme of Action [35] and the National Integrated ECD Policy [7,31], broadly aligns with EHDI principles of timely intervention as promulgated by the HPCSA [19,20]. The DSD [65] (p. 7) has long expressed this in its Guidelines for ECD Services, where ECD is defined as “the process of emotional, mental, spiritual, moral, physical and social development of children from birth to nine years”. The DSD [65] (p. 15) further expressed, “Children who have any kind of disability should have special care and support so that they can lead full and independent lives”. The proliferation of more than 120 costing and evaluation, programme, and policy documents pertaining to ECD [79] attests to the DSD’s commitment to addressing South African-specific challenges, such as the need for better governmental inter-sectoral collaboration.

The DSD, DoH, and DBE have provided separate but sometimes collaborative input as stakeholders together with parents and caregivers. The NIECDP [7,31] defines the ECD time frame until formal school entry or, for children with disabilities, “the year before the calendar year they turn seven (7), which marks the age of compulsory schooling or special education”. The policy’s purpose includes the following:

• Providing an overarching multi-sectoral enabling framework of ECD services, inclusive of national, provincial, and local spheres of government;
• Defining a national comprehensive ECD programme and support, with identified essential components;
• Identifying the relevant role players and their roles and responsibilities for the provision of various components of ECD services;
• Establishing national integrated ECD leadership and coordinating structure.

Within the National Integrated ECD Policy [7,31], HI/d/D is referred to indirectly as a sensory impairment, stipulating that “Securing the universal right of children with disabilities to ECD thus requires the public provision of universally available, inclusive, comprehensive ECD services which will ensure the survival, growth, development and protection and participation of all children with disabilities to their full potential”. The White Paper on the Rights of Persons with Disabilities [8] further mandates two key directives:

• Children with disabilities must have equitable access to all ECD programmes and activities;
• Development of disability-specific intervention and support services—where disabled children should be “enrolled in appropriate ECD and compulsory education programmes”.

A significant challenge within the broader government sector is the South African Treasury’s equitable share formula for provincial fund apportionment, calculated according to specific contextual considerations and service delivery demands. Central government apportionment of education funding is not necessarily spent on education per se [80], with certain provinces such as Gauteng and the Northern Cape spending more on education than their equitable share received [81]. This autonomy regarding fund prioritisation applies to social development, basic education, and health services [82], resulting in different strategic emphases across provinces. An example is Gauteng Province’s budget, unlike other provinces, which has emphasised catering for learners with disabilities through inter-sectoral infrastructure collaboration with the Department of Infrastructure, including construction of special needs schools and grant support for learners [83]. This dissimilar directive across provinces has created a disparity in disability services rendered. Where standardisation is attempted through the example of national health guidelines on assistive device provisions (including hearing aids and cochlear implants), such services are often difficult to actualise due to budgetary constraints [84]. Burger [85] notes that services for children under five years, especially those with developmental delay, are adjudicated in a non-standardised fashion, possibly related to the lack of standardised policy evident within and between stakeholder documentation.

Within this non-standardised context, the HPCSA EHDI guidelines [20] recognise EI services as crucial for desired outcomes [86], positing government inter-sectoral collaboration as key, together with grassroots stakeholders such as family members and special education provision. Furthermore, the UNCRPD, as ratified by South Africa [4,5], emphasises d/Deaf community linguistic identity promotion with the facilitation of SASL learning with the delivery of education in the most suitable mode and language and in environments that maximise academic and social development. The National Planning Commission’s Disability Background Paper [63] concludes that South Africa has made inroads regarding disability administration, particularly concerning DoH early childhood intervention and EHDI within primary healthcare, with hearing aid provision and special needs schools for children with HI/d/D. The JCIH [16,17,23] advocates for immediate access to quality technology, inclusive of cochlear implants, hearing aids, and other assistive devices as appropriate, with timely access and coordinated entry to EI programmes with qualified providers to facilitate optimal development and well-being [87]. The HPCSA [19,20] similarly recommends speedy access to assistive devices and EI services within a family-centred, culturally congruent, and interdisciplinary program.

However, studies pertaining to South African EHDI actualisation have revealed concerning delays in HI identification, averaging between 23 and 41 months, with hearing aid fitting between 28 and 39 months, and EI uptake between 31 and 43 months [54,88]. Hospital-based, home-based, and centre/preschool-based EI programmes for the hearing impaired are meant to mitigate the negative consequences associated with HI but can only be applied after a diagnosis of HI/d/D. These marked delays significantly reduce the child’s prospects for functioning at a communication level similar to their hearing peers [89]. EI for children with HI/d/D six years and below thus infers an inextricable dependence on basic and specialised education, as mainstream EE is the milieu in which children with HI/d/D are often already placed, given the average delayed diagnosis.

Within the South African context, despite policy recognition and attempts to guide collaborative processes, Naidoo and Khan [59] specifically cite the lack of intersectoral collaboration as a hindrance to EHDI best practice actualisation, with a disconnect between the DBE and DoH. The current non-mandatory EHDI approach compounds the application of EHDI, where HPCSA guidelines [20] are rendered as a choice. As such, Naidoo and Khan [59] recommend mandating EHDI guidelines at a political level to facilitate EHDI progression within the South African context. Given South Africa’s complex population diversity culturally, socio-economically, and linguistically [90], and the constrained budget compared to HIC world contexts [29], a bottom-up approach paired with what Olusanya [91] refers to as a horizontal collaborative model of service provision may assist in successful delivery of services. This vertical–horizontal collaborative design must, however, provide pathway detail, especially in HI/d/D transitioning between government divisions. As such, critical engagement with the many existing policy details is key and must consider community dynamics, cultural and linguistic diversity, fiscal considerations, and access to health, social, and educational processes, with clear navigation pathways among sectors. This comprehensive approach is essential to prevent the continued marginalisation of South African children with HI/d/D, whose rights will continue to be negated until intervention is formalised as part of a mandatory integrated nationalised healthcare, social development, and education strategy. The National DSD, in its collaboration with the DoE and Cooperative Governance and Traditional Affairs through the NIECDP [7,31], makes a concerted attempt to do so, but it is the grassroots workable upstream details that require consideration and inclusion.

5. Conclusions and Recommendations

South Africa has recognised the critical role EI plays in mitigating ECD challenges for children with disabilities with due consideration of aspects such as inclusivity and interdepartmental collaboration. South African policy is robust in its broad-based scope and social justice ideals, where it aims to encapsulate disability in its heterogeneity. However, in so doing, details in relation to specific disabilities such as HI/d/D are mostly lacking across the various government entities in which HI/d/D is contextualised. Consequently, detailed policy directives are required regarding the implementation of HPCSA-specific guidelines. The HPCSA guideline details include recommendations for interdepartmental collaboration. Here, it is imperative that EE be included as a cross-over juncture, as HI/d/D is often diagnosed late within the South African context, where children with HI/d/D may already be attending an ECD centre or pre-school. This process has already been partially in play at a policy level as per specific policy documentation such as the DoH, DBE, and DoH-Integrated School Health Policy (2012) but this is for the older than six-year age range. Practical directive specificity is lacking, specifically regarding children with HI/d/D, age six and under.

To enable the establishment of contextually relevant and effective EI application and practice for children with HI/d/D in children under age six, the following actionable steps are recommended for policymakers, practitioners, and researchers in specific reference to children with HI/d/D:

• Development of policy briefs targeting inter-sectoral collaboration where considerations must include child inter-departmental transitioning pathways.
• Implementation of national standards for EI service delivery informed by the HPCSA EHDI guidelines.
• Mandating EHDI and education policies with specific monitoring and accountability, including monitoring and accountability mechanisms such as a centralised EHDI oversight committee.
• Within the above, judiciously engaging stakeholders such as parents, teachers, and Deaf community members, together with DoH, DBE, and DSD government entities to further understand and ameliorate policy and implementation gaps in a bottom-up approach, with scrutiny at the point of delivery for EI for HI.

Without such formalisation, a marked portion of South African children with HI/d/D will continue to be marginalised. The above-mentioned approach, with grassroots involvement to understanding policy efficacy, is envisaged to impart critical insight regarding the policy realisation process (fiscal, organisational, logistical, infrastructural) for children with HI/d/D six years and below.