International Development CommitteeWritten evidence submitted by Emma Samman and Laura Rodriguez-Takeuchi from the Overseas Development Institute (ODI); Sylvia Beales from Help Age International; Sylvie Cordier and Tim Wainwright from ADD International; Marc Wortmann from Alzheimer’s Disease International (ADI); Marion Steff and Elaine Ireland from Sightsavers.

Voices of the Marginalized and Post-2015 Development Goals

This submission will address two issues requested by the International Development Committee: how progress should be measured, and what should be the content of future development goals. The submission focuses on the need to include inequalities related to disability, mental health and age in the Post-2015 development framework to ensure equal opportunities for all. This could entail specific targets geared to these issues as well as their incorporation as cross-cutting categories across a new set of goals. Improved data collection is needed for more effective monitoring.

The submission is made on behalf of members1 of the following organizations: ADD, ADI, HelpAge International, ODI and Sightsavers. The views expressed and any errors of fact and judgment remain the responsibility of the authors and do not necessarily constitute an institutional perspective.

Inequalities Hold Back Progress Yet are Treated Selectively in the MDGs

1. Inequality takes many forms. Often considered are those inequalities relating to gender, race and ethnicity, class, and region of residence.2 This briefing additionally calls for the inclusion of inequalities relating to older age, disability, and mental ill health.3 All three factors are global in scale, notable for their absence from the MDGs and have salient effects on large numbers of people. They are closely associated with a lack of fulfilment of human rights.

2. The neglect of older age, disability and mental health also constrains the achievement of the MDGs. For example:

Older people may be more susceptible to fatal forms of malaria owing to age-associated loss of immune function (Gavazzi et al. 2004).

Over one-third of school aged children remaining out of school have a disability (Peters 2003) Poor mental health can engender poor physical health, and vice versa (Das et al. 2007).

3. Accordingly, a new agreement must tackle these inequalities into account. A post-2015 agenda built on explicit human rights standards can be used to help States meet the obligations to which these frameworks commit them, and to hold them to account.

Ageing, disability and mental health issues affect sizeable (and growing) numbers of people

4. Older people (aged 60 years and above) currently make up 11% of the global population; this share is expected to double to 22%, or 2 billion people, by 2050.4 For the first time, the population as a whole is ageing. At a global level, the number of older persons already exceeds that of children under five. It is expected to exceed the number of youth 15 years and under for the first time in 2050. The fastest growth is happening in developing countries with profound implications not only for older people themselves, but for their households, for social and community infrastructure, and for social policy. Dementia is projected to rise in relation to the demographic transition to affect 115.4 million people in 2050 (ADI 2012; WHO 2012),

5. Disability is not a rare event. Leading estimates from the World Health Organization’s World Health Survey (WHO 2011) and Global Burden of Disease report (WHO 2008), both using 2002–2004 data, suggest that between 15% and 20% of the population worldwide have some form of disability,5 and that 2% to 4% of people have a severe disability.

6. Mental health disorders account for 13% of the world’s Global Burden of Disease, affecting some 450 million people, or more than six in every 100 people worldwide. Severe Depression affects 99 million people; the share of affected people has risen since 1990 and World Health Organisation predicts that by 2030, depression will affect more people than any other health problem (WHO 2008).

Ageing, disability and mental health issues are linked to multiple forms of disadvantage

7. Ageing is associated with different types of disadvantage. Recent studies in developing countries found that households with older residents tended to be poorer than those without older residents (Masset and White 2007, Kakwani and Subbarao 2007). Moreover, poverty as well as a lack of education and environmental degradation make older people vulnerable to ill-health (UNFPA & HelpAge International 2012), while age discrimination can magnify exclusion (UNFPA & HelpAge International 2012). Ageing may mean that people become less able to work and receive fewer employment opportunities, but policies and programmes designed to enhance livelihoods often exclude older people in promoting activities that require high levels of labour capacity and mobility. Presently some 340 million older people are living without a secure income; on current trends, this number will rise to 1.2 billion by 2050 (Meissner 2010). Between 15% and 30% of older people live alone or with no adult of working age (Masset and White 2004, p. 280). However, only one in five of the older population has a pension and coverage is even lower in developing countries (UNFPA & HelpAge International 2012). Moreover, in many countries where many children have been orphaned by HIV/AIDS, older people are assuming a considerable caretaking burden.

8. On balance, disability is linked to a higher probability of being poor.6 Disabled persons are less likely to obtain an education—owing to constraints on access, stigma and a lack of support—and face reduced employment opportunities and earnings. Additionally, other household members may have to relinquish paid employment in order to care for disabled members. Typically, disabled persons have higher health care costs, and they may also face social and political marginalization (Groce et al. 2011).The poor, in turn, are more likely to be malnourished, to be in low quality employment, to be subject to difficult living conditions and to be exposed to environmental hazards, all of which increase the likelihood of disability. Several meta-studies and studies of particular countries support this relationship. For example:

Analysis of 15 developing countries found that in the majority, “persons with disabilities, on average, experience multiple deprivations at higher rates and in higher breadth, depth and severity than persons without disabilities” (Mitra et al. 2012).

In 13 developing countries, school-age children were less likely to start school or to be enrolled (Filmer 2008).

In Tanzania, households with a disabled member were 20% more likely to be poor (Masset and White 2004); In Uganda, they were 38% more likely to be poor (Hoogeveen 2005).

In India, disabled children were over five times more likely not to be in school, while employment rates for disabled persons were some 60% lower on average (World Bank 2007).

9. Similarly, mental illness is strongly associated with factors that heighten the probability of being socially excluded and poor. This links to attitudes that exclude and stigmatize, as well as ageing, being widowed or being in poor health. Changes in life circumstances brought on, for example by illness and other adverse events may also contribute (Das et al. 2007). A recent meta-review found that “education, food insecurity, housing, social class, socio-economic status and financial stress” are consistently related to common mental disorders (Lund et al. 2010).

10. Stigma and negative social perceptions stemming directly from the physical or mental impairments or indirectly from disadvantaged living conditions impedes the advancement of basic rights. For example, fear of stigmatization has been found to be a barrier to revealing and to seeking treatment for mental health problems (Kessler 2000). Similarly, the recent World Alzheimer Report (ADI 2012) shows that two-thirds of people with dementia and their carers feel excluded from society.

These inequalities are neglected in many countries and in the international arena

11. The existence of rights instruments should be an important means to support actions on inequalities in the global arena and within countries. Better and affordable health care is needed in much of the world, as is support for livelihoods, education and other dimensions of wellbeing.

12. There is as yet no international convention on the rights of older persons although calls are growing given the extent and prevalence of age discrimination and a recognised gap in protection. The 2002 Madrid International Plan on Ageing was the first to make explicit connections between development aims and human rights. It remains the only global agreement that commits governments to integrate issues related to ageing into economic and social development policies and the MDGs. Yet the MDGs “completely ignore the ageing of societies and poverty in old age” (Meissner, 2010), a finding echoed by the UNDP (UNFPA & HelpAge 2012). The right to an adequate standard of living is routinely denied to older people through the absence of a pension, although several studies point to their feasibility even in low-income settings. Policies are needed in other areas that affect older people in particular ways such as caretaking responsibilities and tackling domestic and institutional abuse and violence.

13. The 2006 Convention on the Rights of Persons with Disabilities marked an advance for the rights of disabled persons but member states now need to work towards further implementation of its commitments. The UN General Assembly Resolutions (2008, 2010) reinforced the need for greater attention to disability and highlighted the statistical invisibility of disabled people. Even though people with disabilities are not explicitly included in any of the MDG targets and indicators, the 2010 and 2011 MDG Reports acknowledged the needs of disabled people but the 2012 Report did not. Greater attention—both in monitoring and programming—is needed. At a national level, the relationship between disability and poverty varies greatly according to the availability of health care, nutrition programmes, disability benefits and accessible schooling, highlighting the important role of policy (Mitra et al. 2012).

14. Mental health “remains a largely ignored issue in global health, and its complete absence from the MDGs reinforces the position that mental health has little role to play in major development-related health agendas” (Miranda and Patel 2005). There is unmet need for mental health treatment, particularly in developing countries. In Colombia, Lebanon and Mexico, an estimated 76% to 85% of people with severe mental health conditions do not receive treatment, and even in high income countries, unmet need is estimated at between 35% and 50% of people with severe conditions (World Mental Health Survey Consortium 2004). Resources are part of the problem: one third of the world’s countries do not have any health budget allocation for mental health while in a fifth of those that do, the allocation is less than 1% of the total health budget (Mental Health and Poverty Project & WHO 2010). Stigma about mental health also impedes treatment. Given the extent of mental health issues, the failure to address them effectively is a fundamental denial of the right to health of mentally ill persons.

How progress should be measured: Tackling inequalities relating to age, disability and mental health in a post-2015 framework

15. A post-2015 framework presents an invaluable opportunity to tackle inequalities at a global level and to further advance commitment to the rights frameworks that pertain to these three particular types of inequalities. The integration of rights based monitoring is essential to ensure compliance with the international human rights framework.

16. To mainstream inequalities relating to age and disability, inclusive data collection and analysis is essential. This could occur by requiring that data used for establishing a baseline and monitoring the progress of future targets be disaggregated by age category and by disability status. The extent to which these—another other—inequalities overlap and reinforce one another should also be taken into account. For example, older people are much more likely to be disabled—indeed, 38% of older people worldwide have disabilities (WHO 2011, Groce et al 2011) and older, disabled people are more likely to be multidimensionally poor than those who are not disabled (Mitra et al. 2012). Women are more likely to be disabled than men (WHO 2011) and more likely to experience some mental disorders (Das et al. 2007). Physical and mental ill health often is linked.

17. Specific goals can also be considered. Disability could be explicitly included across targets related to employment, education and health, etc. A target devoted to mental health would have the potential to benefit several hundred million people. Age inclusive targets to ensure an increase in healthy life expectancy at birth and to reduce the time spent in ill health could be adopted. Goals aiming at health and income security though the extension of social protection floors would benefit all people affected by economic inequalities.

Improved monitoring of age, disability and mental health status is needed

18. The situation of older people, disabled people and those with mental health issues is often invisible. A lack of data and monitoring mechanisms for these issues conceals exclusion and inequalities and makes it impossible to dismantle entrenched patterns of discrimination. Particularly lacking are data from nationally representative household surveys used to monitor other MDG targets, which would permit a multidimensional perspective on how older people, people with disabilities and mental disorders are faring, the circumstances of their households, and their access to services. In particular it would permit a focus on how old age, disability, mental health issues, and overlap with other markers of disadvantage. It would also allow better monitoring of the distributional impact of policies and budget allocations on different populations. The most efficient means of eliciting relevant information on these topics in a global context is through internationally comparable household surveys, such as those administered by World Bank (namely the Living Standards and Measurement Survey), Macro International (Demographic Health Survey) and UNICEF (Multiple Indicator Cluster Survey).

19. It is feasible to collect data on these three types of inequality in standard household surveys. The UN’s Washington Group on Statistics has recommended a simple set of questions to establish the prevalence and severity of disability, by asking about difficulties individuals face in seeing, hearing, mobility, cognition, self-care, and communication. Mental health conditions are more challenging to identify, screening questionnaires can reliably elicit the prevalence of common mental disorders and can be successfully incorporated into large and nationally representative standard household surveys (Das et al. 2007). Shorter screening modules that have been shown to function effectively include the K6 and K10 questionnaires, General Health Questionnaire (GHQ-12) and Mental Health Inventory (MHI-5),7 though further validation is needed in some developing country contexts.

20. Household surveys could become more age sensitive if greater attention were paid to ensure coverage of older people and that the data are representative of older age groups—which may in turn require some oversampling. In addition more attention should be paid to the allocation of resources within households and to issues such as violence, care taking and social relationships. Finally there is a need to extend the coverage of household surveys to those living outside traditional households—namely those living on the streets, in different types of institutions such as residential care facilities, long-stay hospitals or orphanages– to get a more accurate picture of how society as a whole is faring.

Conclusions

21. The MDGs do not address inequalities that are associated with age, disability and mental health; this has constrained their attainment and reinforced these inequalities. A new post-2015 framework should be sensitive to these three issues, advancing the commitments specified in international human rights frameworks, and ensuring that they are adequately measured and monitored.

October 2012

References

Alzheimer’s Disease International (ADI) (2012), World Alzheimer Report 2012, Overcoming the stigma of dementia, London, ADI, http://www.alz.co.uk/research/world-report

Das, J, Q Do, J Friedman, D McKenzie and K Scott (2007), “Mental health and poverty in developing countries: Revisiting the relationship”, Social Science & Medicine 65, p. 467–480.

Filmer, D (2008), “Disability, poverty and schooling in developing countries: results from 14 household surveys”, The World Bank Economic Review 22:1, p. 141–163.

Groce, N, G Kembhavi, S Wirz, R Lang, J-F Trani and M Kett (2011), “Poverty and disability—a critical review of the literature in Low and Middle Income Countries”, Working Paper Series No. 16, London: UCL Leonard Cheshire Disability and Inclusive Development Centre.

Hoogeveen, JG (2005), “Measuring welfare for small but vulnerable groups: poverty and disability in Uganda”, Journal of African Economies 14:4, p. 603–631.

Kessler, RC (2000), Psychiatric epidemiology: selected recent advances and future directions. Bulletin of the World Health Organization, 78(4)

Lund C, Breen A, Flisher AJ, Kakuma R, Corrigall J, Joska JA, Swartz L, Patel V (2010), “Poverty and common mental disorders in low and middle income countries: A systematic review”, Soc Sci Med 71:3, p. 517–28, Aug.

Masset, E and H White (2004), “Are Chronically Poor People being Left Out of Progress Towards the Millennium Development Goals? A quantitative analysis of older people, disabled people and orphans”, Journal of Human Development 5:2, p. 279–297.

Meissner, M (2010), “Ways out of old-age poverty”, Available at: http://www.dandc.eu/articles/178158/index_p.en.shtml.

Melamed, C (2012) “Putting inequality in the post-2015 picture”. Overseas Development Institute, London.

Miranda JJ and V Patel (2005), “Achieving the Millennium Development Goals: Does Mental Health Play a Role?” PLoS Med 2(10): e291. doi:10.1371/journal.pmed.0020291

Mitra, S, A Posarac and B Vick (Forthcoming, 2012), “Disability and Poverty in Developing Countries: A Multidimensional Study”, World Development, 2012, http://dx.doi:10.1016/j.worlddev.2012.05.024.

Peters, S (2003). Education for All: Including children with disabilities, Education Notes (August 2003), http://siteresources.worldbank.org/DISABILITY/Resources/280658–1172610312075/EFAIncluding.pdf

UNESCO (2010). Education For All, Global monitoring report. Reaching the marginalized, UNESCO and Oxford University Press, Paris and Oxford.

UNFPA and HelpAge International (2012), “Ageing in the 21st Century a celebration and a challenge” London 2012

UNICEF, UN Women, UN DESA, UNRISD, ESCAP, ECE (2012) Addressing Inequalities: The Heart of the post-2015 development agenda and the future we want for all. Background thematic paper prepared for the UN Task Team on the post-2015 development agenda.

World Bank. (2007). People with Disabilities in India: From Commitment to Outcomes. May 2007. http://siteresources.worldbank.org/INDIAEXTN/Resources/295583–1171456325808/DISABILITYREPORTFINALNOV2007.pdf.

World Health Organization (2008), Global Burden of Disease, Geneva: WHO.

World Health Organization (2011), World report on disability, Geneva: WHO.

World Health Organization (2012), Dementia: A global Health Priority, Geneva: WHO.

World Health Organization World Mental Health Survey Consortium (2004). “Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Survey”, Journal of the American Medical Association 291(21): 2581–1590.