There is a proverb that says, he who wears the shoe is best placed to tell us where it pinches. At first glance, it appears to be a simple call for empathy. In reality, it embodies a profound principle of governance, healthcare and the law. It reminds us that those who live with a problem possess a form of knowledge that cannot be acquired through observation alone. They understand barriers not because they have studied them, but because they experience them every day.

This philosophy lies at the heart of the modern disability rights movement. For generations, disability was approached through a paternalistic lens. Governments, professionals, institutions and even charitable organisations determined what they believed persons with disabilities needed, often with the noblest of intentions. Yet good intentions do not always produce good outcomes. Increasingly, the law has recognised that decisions affecting persons with disabilities should not simply be made on their behalf but with their meaningful participation. This evolution is captured in one of the most powerful principles of disability rights of Nothing about us, without us.

That principle extends well beyond disability. It speaks to a broader truth about healthcare itself. Effective healthcare systems cannot be designed solely from boardrooms, government offices or hospital management meetings. Nor can they be understood from a single perspective. A healthcare system is experienced differently by patients, by their families and caregivers, by doctors, nurses, therapists, pharmacists, social workers, clinical officers, community health workers, reception staff, hospital managers and policymakers. Each sees a different part of the same system. None, by itself, sees the whole.

One of the greatest challenges in healthcare policy is that solutions are often designed from the perspective of institutions rather than from the perspective of those who live within the system. Institutions naturally focus on the parts of healthcare they control, while patients and frontline professionals experience healthcare as a continuous journey that extends far beyond the walls of any hospital. When these different perspectives are not brought together, healthcare systems risk solving the problems they can see while overlooking those that actually prevent people from accessing care.

Perhaps nowhere is this more evident than in discussions about accessibility for persons with disabilities. Whenever accessibility is mentioned, attention almost immediately turns to ramps, elevators, accessible toilets and designated parking spaces. These features are undoubtedly important and represent an essential step towards inclusive healthcare. Yet the very fact that they dominate the conversation illustrates how easily accessibility becomes reduced to the physical environment of the hospital.

Consider a person who uses a wheelchair and requires urgent medical attention. From the perspective of the hospital, accessibility begins at the hospital entrance. The institution quite rightly prides itself on having ramps, wide corridors, accessible consultation rooms and appropriately designed washrooms. From the perspective of the patient, however, the journey began much earlier. It began the moment the need for healthcare arose. If public transport cannot accommodate wheelchairs, if pavements are impassable, if pedestrian crossings are inaccessible or if specialised transport is unaffordable, the patient may never reach the hospital at all. In such circumstances, the hospital may be fully compliant with every architectural standard while healthcare itself remains inaccessible. The greatest barrier did not exist at the hospital entrance; it existed several kilometres away, at the point where the patient first attempted to leave home.

This simple example illustrates an important systems principle. Accessibility should not be measured from where the institution begins but it should be measured from where the individual begins. A healthcare organisation naturally sees the patient from the moment they enter its premises. The patient experiences healthcare from the moment the decision is made to seek help. The difference between these two starting points explains why healthcare providers and patients sometimes reach very different conclusions about whether a service is truly accessible.

Equally important is the tendency to equate disability almost exclusively with mobility impairment. This narrow understanding inevitably produces equally narrow solutions. Physical accessibility is essential, but it represents only one dimension of accessibility. A person who is deaf may enter the hospital without difficulty yet remain unable to communicate because no sign language interpreter is available. A patient with visual impairment may receive appointment cards, consent forms or discharge instructions that cannot be read independently. Someone living with an intellectual disability may struggle with administrative procedures or consent processes that assume levels of comprehension without providing appropriate support. An individual with autism may find a crowded outpatient department overwhelming because no consideration has been given to sensory sensitivities. People living with psychosocial disabilities may encounter stigma or systems that fail to accommodate their particular needs. None of these barriers can be removed by constructing better ramps because they do not arise solely from the physical environment. They arise from systems that have been designed around assumptions of what constitutes the "ordinary" patient.

Modern disability jurisprudence has increasingly recognised that disability does not arise solely from an individual's impairment. It also arises from the interaction between that impairment and the barriers created by society. The legal and moral question has therefore shifted. Rather than asking how persons with disabilities can adapt to existing systems, we are increasingly asking how systems should adapt to accommodate the diversity of human experience. Accessibility consequently ceases to be an act of charity or goodwill. It becomes a question of equality, dignity, inclusion and justice.

Identifying those barriers requires more than technical expertise. Engineers understand construction, architects understand design, lawyers understand legislation, clinicians understand disease and policymakers understand governance. Equally valuable, however, is experiential expertise. Persons with disabilities understand where barriers exist because they encounter them daily. Family members and caregivers understand the practical realities of supporting individuals as they navigate healthcare over months or years. Doctors, nurses and other frontline healthcare professionals understand where systems work well and where they fail because they confront those challenges during every clinical encounter. Hospital managers understand organisational constraints, while policymakers appreciate the complexities of financing, regulation and public accountability. Each perspective contributes a different form of evidence. None is sufficient on its own.

This is precisely why meaningful participation matters. Consultation should never be viewed simply as an exercise in inclusion or public relations. It is a means of improving decision-making. Healthcare systems function best when they are informed by those who seek care, those who support care and those who deliver care. The objective is not merely to hear different voices but to understand different realities. Policies developed without listening to those who experience their consequences are far more likely to address visible problems than real ones.

Healthcare organisations frequently describe themselves as patient-centred, yet genuine patient-centred care begins long before a patient meets a doctor or nurse. It begins when healthcare policies are formulated, transport systems planned, budgets allocated, information designed, communication strategies developed and administrative procedures established. If persons with disabilities, caregivers and frontline healthcare workers are absent from those conversations, then patient-centred care has already been compromised before the first consultation takes place. By the time the patient enters the consulting room, many of the decisions that determine accessibility have already been made.

Contemporary constitutional and human rights jurisprudence increasingly reflects this broader understanding. The emphasis has shifted from the passive provision of services towards meaningful equality, participation, dignity and inclusion. The measure of justice is no longer whether identical services are theoretically available to everyone, but whether every individual has a genuine opportunity to benefit from those services. Equality does not necessarily mean treating everyone identically. It means recognising that people begin from different circumstances and ensuring that avoidable barriers do not prevent them from participating fully in society.

Ultimately, the challenge before healthcare is not simply to build more accessible hospitals. It is to build more accessible healthcare systems. That requires humility to recognise that no single profession, institution or stakeholder possesses a complete understanding of the healthcare journey. It also requires the wisdom to listen to those whose lived experiences reveal barriers that statistics, policy documents and architectural drawings often fail to capture.

The old proverb therefore remains as relevant today as ever. He who wears the shoe is indeed best placed to tell us where it pinches. In healthcare, however, there is more than one person wearing the shoe. Patients, families, caregivers, doctors, nurses, allied health professionals, support staff, managers and policymakers all experience different pressures from the same system. If we genuinely wish to move from policy to practice, we must first understand where the system pinches for each of them. Only then can we design healthcare that is not merely available, but truly accessible.