The International Classification of Functioning, Disability and Health (ICF): a portrait

Author: Fabian Diesner (Swiss Paraplegic Research)

To get clear about what it means to be healthy, the World Health Organization (WHO) developed first a framework and then a unified and standardized language for the description of health, health-related states and in the year 2001: the International Classification of Functioning, Disability and Health (ICF). Since the ICF has become a very important player in the game of rehabilitation, research, health services and policies, we want to shed some light on the red book that has helped us to make sense of health and disability.

One brand – two products

First of all, it is very important to highlight that the ICF has two sides: one is the philosophical and conceptual model and framework of health and functioning, and the other is the application-oriented classification with its unique coding system.
Let’s start with the basic model that is our point of departure. Before the ICF was developed, other conceptual frameworks tried to capture the full scope of health conditions and their consequences. But the ICF brought a new concept to the field -- “functioning”. This term summarizes all body functions, activities and participations in relation to a person’s life situation. The opposite to functioning is disability, which signifies impairments, activity limitations or participation restrictions. Both concepts describe things that only exist in coexistence with our environment as well as with the personal background that constitute every one of us. Therefore, the ICF not only disentangled the dichotomy between “healthy and unhealthy” but also shifted the paradigm towards the human lived experience.
The comprehensive model depicted below shows the interconnectedness and dependency of our health related constituents. In addition, the illustration shows nicely that the ICF framework consists of five domains that all have an equal influence on our health condition and the lived experience: body functions and structures, activities, participation, environmental and personal factors.
Since this model serves more like a basic philosophy of health, the WHO developed the ICF classification based on this framework to provide health care stakeholders with a standardized and universal language of functioning for the clinical setting as well as for service providers’ and policymaking processes. An example might help to highlight the benefit of using the ICF categories for the communication between health and health-related professionals.
Let’s say we have three people with a tetraplegia, all of them with the diagnosis of C5 complete. This assessment does not say anything about each person’s individual level of functioning or their capacities. The ICF categories, however, can help to describe any physical, environmental, participatory or activity related factor that allows us to make a detailed description of the person’s individual level of functioning. Whereas one person might have moderate problems with limited hand function, another might be able to compensate this performance problem by sheer willpower, physical skill or other individual strategies. Since the ICF categories represent each individual’s capacity and performance, for example rehabilitation staff but also service providers of an insurance gain invaluable insight of the person’s health condition which then allows for specific and individual interventions and service provision.
The classification integrates the five domains depicted in the illustration above and organizes them according to categories that describe basic physical functions up to very complex functions like having and keeping a job. By structuring and universalizing human functioning in relation to external environmental factors, it is now possible not only to design a comprehensive profile of a person’s health condition, it is also possible for that profile to be used across health related professions.

Aims and application of the ICF

The aims of the ICF classification are to improve the communication between different users in the health care sector, but also between researchers, policy makers and the wider public, including people with disabilities. Furthermore, the unified coding system allows to compare data across countries (providing an international context), health care disciplines and time.
The holistic character of the ICF framework and classification make its application areas manifold.
It can be used as a statistical tool to collect and record data (surveys, studies, population studies), it can serve as a research tool to measure outcomes, quality of life, and environmental factors. When it comes to need assessments matching treatments with specific conditions, vocational assessment, rehabilitation and outcome evaluation, the classification can be a very valuable clinical tool which also holds true as a social policy tool for security planning, compensation systems, and policy design in the field of health. Last but not least, the ICF classification can serve as an educational tool with regard to curriculum design, for raising awareness or to undertake social action.
One could say that the ICF is a new organizational system for health-related information and that it has the potential to negotiate via a standardized, universal language between health professionals, funding agencies and policymakers to increase the quality of life, chances and fair opportunities of people with a health condition.