International Development CommitteeWritten evidence submitted by Sightsavers

Introduction

1. Sightsavers is an international charity which works with partners to eliminate avoidable blindness and promote equality of opportunity for disabled people in the developing world. Our vision is a world where nobody is blind from avoidable causes, and where people who are visually impaired participate equally in society.

The Existing Framework

Success of the Millennium Development Goals

2. The Millennium Development Goals (MDGs) as a framework have galvanised political will and financial. This has also been made possible by the clear and concise nature of the MDGs, which has enabled civil society organisations to advocate and hold national governments and donor agencies accountable for achieving the goals.

3. The MDGs have significantly contributed to reducing poverty rates, and the number of people in absolute poverty has declined since the adoption of the MDGs by 189 governments in 2000. Taken together, developing countries have already attained MDG 1—that of halving the 1990 incidence of extreme poverty by 2015.ⁱ Significant progress has been made in reducing mortality for children under five years of age, reducing maternal mortality, improving nutrition and reducing disability and death owing to HIV infection, tuberculosis and malaria. Between 1990 and 2010 under-five mortality declined by 35%,ⁱⁱ and in 2010, 15% fewer people were newly infected with HIV than in 2001.

4. Impressive achievements have also been made in the fight against neglected tropical diseases (NTDs), the group of 17 diseases that affect more than one billion people. Although not specifically identified as a target by the MDGs, the significant and demonstrable achievements in addressing NTDs would not have been possible in our view without the focus on other diseases outlined in MDG 6.

Challenges

5. However, the MDGs have also created challenges. For those services, or population groups, that are not covered in the MDGs, it has become harder to make progress. The current MDG framework fails to acknowledge that disability is a both a cause and consequence of poverty—a serious and notable gap. Access to education has increased, but the quality of education has lagged behind; and while access to HIV, TB, malaria and maternal health services has improved, other services, such as provision of eye health care to prevent avoidable blindness, have been neglected. The focus on targeted health interventions has also meant that less attention has been paid to systemic issues, such as the health workers, information, and medical supplies that are critical to provide good quality health care.

6. The lack of effective monitoring mechanisms at sub-national level, and the absence of data disaggregated by disability, gender, ethnicity, and wealth quintile, has led to the unintentional masking of significant disparities in areas such as health, education and gender. There are strong relationships between blindness and poverty, and blindness and visual impairment with low educational attainment for children. Without clear data at sub-national level about the health challenges people face, progress against the MDGs for the hardest to reach will continue to stagnate.

7. A critical gap has been attention to equity and ensuring marginalised populations, such as disabled people, are able to benefit from increased resources for health, education, and so on. Policy makers are not required under the MDG framework to report against specific targets for progress for the poorest and most vulnerable.

Poverty and disability facts

UN estimates suggest that 15% of the global population lives with a disability and disability is associated with 20% of global poverty.ⁱⁱⁱ

Disabled people have lower educational attainment and thus experience lower employment rates than non-disabled people^iv increasing their risk of poverty or social exclusion.

Disabled children constitute more than one-third of the approximately 67 million children who are not enrolled in school. In Africa less than 10% of disabled children attend primary school.^v

Poverty can also increase the risk of disability through poor living conditions, access to health care or safe water.

8. The MDG framework is not as comprehensive as the Education for All agenda.^vi In particular, two of the three pillars of basic education—early childhood care and education and lower secondary education—are absent from the MDG framework. The quality of education was not considered by the MDG framework, which only considers access to (primary) education. Finally, it would have been useful for the MDGs to explicitly stress the need to target the most excluded and vulnerable population groups. There is a lack of good data on disabled children’s school attendance, but in many countries it is a significant factor. Having a disabled parent also makes it less likely that children will be able to access education: for example, it increases the likelihood of seven to sixteen year olds never having been to school by 25% in the Philippines and 13% in Uganda.^vii

9. The MDGs have led to significant increases in aid to health (from 2000 to 2006 development assistance to health rose from US$6.8 billion to US$16.7 billion) and a proliferation of global health initiatives. However, the focus on single-disease control initiatives under the MDG framework has not led to significant investment in health systems. A functioning heath system is critical to good health and eye health. Up to 80% of global blindness is preventable or treatable; however, less than 30% of those who need it have access to eye health services in Africa, and in many countries this falls to less than 10%.^viii

10. By 2020, it is anticipated that 75% of countries will have been verified as free from blinding trachoma as a public health problem^ix (WHO, 2012a). However, significant challenges to progress remain. Access to clean water and sanitation is critical in eliminating trachoma in vulnerable populations. The safe water goal has seen significant gains in high population countries and is likely to be met in population terms; however there has been erratic progress in smaller countries, with 60% of countries projected to fail the MDG target.^x In 2010, 2500 million people lacked access to improved sanitation facilities and 72% of these lived in rural areas.^xi From a health perspective it is critical that the post-2015 development agenda continues to take a strong policy lead on the social determinants of health which include water and sanitation.

Other Policy Frameworks

11. With a policy agenda so driven by the MDGs, other areas such as disability or eye health not addressed by any of the eight goals and associated targets and indicators struggle to gain political attention and resources. In some cases alternative policy frameworks have been developed to try and address this gap; such as the 2009–2013 WHO Action Plan on Avoidable Blindness and the Vision 2020 targets. Both contributed to the development of national eye health plans, but these plans are frequently not implemented due to a lack of government commitment and resources for eye health.

12. The Australian Agency for International Development (AusAID) developed a disability policy, which was influenced more by the UN Convention on the Rights of Persons with Disabilities (CRPD) than by the MDGs. Similarly, their avoidable blindness initiative was developed in response to Vision 2020. In some key policy areas such as these the MDGs have made it harder to draw attention to these issues, while those policies that have been developed that address them have not really been influenced by the MDGs.

The Process

13. The UN estimates suggest that more than one billion people—15% of the global population—lives with a disability; of these, an estimated 245.5 million people are visually impaired and 39.8 million people are blind. The prevalence of disability is on the rise with increasingly ageing populations and increases in the burden of non-communicable diseases and mental health disorders. A global development framework that promotes the inclusion of disabled people in all forms of development would have a very significant impact, supporting them to become active citizens within their communities and thus contributing to as well as benefiting from the human, social and economic development of their communities and countries.

14. In developing countries, disability is associated with multi-dimensional poverty, suggesting that disabled people should be explicitly incorporated into policy-making frameworks.^xii The lack of inclusion of disabled people in the MDG framework is a significant gap and has meant that not only are a number of the MDGs unlikely to be achieved, but also that disabled people have not benefited from increased investments in health, education and other services. To avoid this happening in the next framework it is critical to ensure the voices of disabled people are heard in the development of the successor framework to the MDGs. Opportunities must be provided to ensure that blind, visually impaired and disabled people are able to participate.

The New Framework

15. Sightsavers is calling for a set of globally agreed goals that all countries will contribute to achieving. The framework should allow national governments to prioritise the goals that are of most relevance in their countries and set national and sub-national targets that they can be held accountable for. This would also enable countries to develop specific goals for the most excluded or poorest groups, such as disabled people.^xiii

16. In Sightsavers’ view, the primary purpose of a future framework is:

To provide an internationally agreed vision of a sustainable human development framework, that is inclusive and universally applicable to all countries including in the industrialised world (where consumption patterns will need to change in order to accommodate improved and sustainable living standards for people living in poverty).

To acknowledge and support the fulfilment of agreed human rights instruments including the UN Convention on the Rights of Persons with Disabilities.

To achieve demonstrable, measureable outcomes that will lift people out of poverty and secure human, social and economic development for all, especially the most marginalised.

To provide a globally agreed framework for action that enables citizens to hold their governments accountable for the commitments they make.

17. Progress in many countries has stagnated because the MDGs have been unable to reach the poorest. As gaps in income levels within and between countries persist, their consequences for health have come into sharper focus.^xiv A principle of equity in development goal settings needs to address equity of opportunity and outcomes.^xv Equity of outcomes means not just providing the essential institutions—such as schools or health facilities—that provide quality services, but taking into account the diversity of people’s needs, such as people living with disabilities, and developing processes that enable people to participate in decision-making in services that affect them.^xvi

18. A limited number of clear, concise goals with measurable indicators and a clear timeline would be beneficial in terms of mobilising and maintain political and public support. The indicators should not be burdensome, but enable the global communities to measure real progress at global, national and sub-national level with high quality data, disaggregated by gender, disability, ethnicity and wealth quintile.

19. It is also important that the next development framework continues to have a focus on social sectors, in particular health, education and social protection, as these are all critical to lifting people out of poverty. Sufficient consideration must be given to emerging and previously neglected health issues, such as non-communicable diseases, eye health, and neglected tropical diseases (NTDs), due to the increasing burden of ill health they cause and the likelihood that with an ageing world population their prevalence will increase. While the number of people living long-term with HIV and AIDS grows as a result of increased access to antiretroviral therapies, there is a corresponding increase in the number of people at risk from conditions such HIV retinopathy, which occurs in about 50% of people living with HIV and AIDS and can lead to blindness. Of the 34 million people currently living with HIV and AIDS, between 50% and 70% will have eye health problems.^xvii Universal health coverage must be a priority in the next development framework—ensuring that people have equitable access to health care (and importantly effective strong primary health care) and protecting people from catastrophic health costs.

20. The new framework should aim to incorporate more aspects of the Education for All agenda.^xviii In particular, a greater focus is needed on the quality of education and education at levels other than primary. Disabled children, and the children of disabled parents, are less likely than other children to attend school; specific and targeted efforts must be made to ensure they benefit from expanded education services, and schools, curricula, teacher training and teaching materials must all be made inclusive of disabled and visually impaired children.

21. Social protection has been discussed as a potential issue for inclusion in a replacement MDG framework. Sightsavers supports the idea of expanding access to social protection in a way relevant to the needs of a particular country context. While social protection has the potential to overcome some of the problems associated with poverty and marginalisation, it is not a panacea and must not replace accessible and quality basic services. Social protection can be helpful for disabled people in overcoming some of the additional costs associated with disability; however, disabled people must also have access to good quality healthcare, transport, education and other services.

Sustainable Development in a new framework

22. A paper from the UN Task Team recently described health as a contributor to the achievement of the MDGs; a potential beneficiary of sustainable development; and a way of measuring progress across sustainable development policy.^xix

Case study: Inclusive Disaster Preparedness in Bangladesh

With climate change affecting water levels all over the world, Bangladesh is especially stricken by severe flooding, as 75% of its land is only ten metres above sea level. Communities and livelihoods are regularly threatened by these environmental disasters, but community members who are disabled find themselves even more vulnerable, reliant on disaster relief just to get by. 

A successful application to 2011’s Sightsavers Innovation Fund has led to a project examining the effects of climate change on the lives of people with disabilities, and how to ensure that disaster preparedness activities are responsive to their particular needs. The project involves 278 disabled adults in two regions, to help increase their self-reliance and to work with local government in order to help make development and disaster relief plans sensitive to the needs of people with disabilities. It will also investigate alternative livelihoods for areas prone to the effects of climate change.

23. The Rio outcome document says that an “effective institutional framework for sustainable development… should… promote synergies and coherence; seek to avoid duplication and avoid unnecessary overlaps”. In order for the goals of sustainable development and poverty eradication to be achieved, it is important to avoid competition. For this reason we would like to see the Sustainable Development Goals developed using the same process and framework that is already in place to decide what will replace the Millennium Development Goals, to ensure coordination and maximise international commitment to the end result.

The Role of Non-State Actors

24. It is important to recognise that the private sector, in addition to NGOs, international partnerships and foundations, the BRICS and civil society, already plays an important role in development. For example, the pharmaceutical company Merck has committed to donating as much of the drug Mectizan® as it is needed for as long as it needed to achieve the global elimination of river blindness. This public-private partnership is the longest running, disease specific, drug donation programme of its kind.

25. It is essential that as the private sector and other new actors become increasingly engaged in development issues, they are encouraged to work with national governments and in support of existing national institutions, structures and services such as public health and education services and avoid creating new unsustainable, parallel structures. When involving the private sector in development, the principle of equitable access to basic services for all must be maintained, and all programmes which involve private actors should be subject to appropriate national scrutiny and regulation. In addition, those government agencies responsible for regulation and oversight must be supported to develop those capacities to ensure services provided are of appropriate quality and accessible to all.

Development Financing

26. The post-MDG framework provides a timely opportunity for a review of development financing, which has become increasingly fragmented. In the health sector for example, there are well over one hundred major international organisations and partnerships, and hundreds of channels for delivering health aid. This vertical programming and subsequent financing in health has seriously undermined the capacity of many health systems to deliver primary health care and meet the most basic needs of the population. At the same time it is also noted that much of the progress made in recent years has been made through vertical programming, so it is important that the ability to deliver is not lost in the move to systems-strengthening support.

27. Resources need to come from continued investment in sustainable international development, from international development and development cooperation budgets; but it also needs to go beyond this. National governments all need to take responsibility for generating the necessary resources to finance their health, education and social welfare systems through, for example, building their tax base and through efforts to improve the fiscal space for investment in the social sectors. What is critically important is a commitment from both developed and developing countries to use all of the resources and financing mechanisms at their disposal to generate the necessary domestic and international resources to make more rapid progress towards sustainable human development.

Conclusions

28. In Sightsavers’ view, the important elements to ensure in any future development agenda include:

An approach to development that is inclusive of agreed human rights conventions, including the UN CRPD, and that is developed in consultation with those whose rights are furthest from being fulfilled.

A focus on poverty eradication that has at its core sustainable social, economic and human development and a framework that is underpinned by the principle of equity—ensuring equality of opportunity and outcomes

A simple, measurable framework, with global goals but with targets developed at national level.

29. The features which must be avoided in any future development agenda include:

The exclusion of disability from the new development framework, and processes that exclude the poorest from participation and do not enable the voices of the marginalised to be heard.

A continuation of the processes that fail to measure, monitor or report on inequities between and within countries. Targets and indicators must be differentiated at national and sub-national level with data disaggregated by gender, disability, and ethnicity, wealth quintile to ensure that the needs of the most marginalised are constantly monitored and met.

A focus on economic issues alone. Realistic, achievable goals and targets must be developed that do not focus solely on economic dimensions but take account of social and environmental dimensions too.

A framework that excludes a focus on governance—and in particular institutions that support access to equitable public services such as education and health (enabling effective health systems strengthening).

October 2012

References

i World Bank (2012) an update to the World Bank’s estimates of consumption poverty in the developing world. Washington D.C., 2012. Available at: http://siteresources.worldbank.org/INTPOVCALNET/Resources/Global_Poverty_Update_2012_02-29-12.pdf

ii WHO (2012b) Monitoring the achievement of the health-related Millennium Development Goals. Sixty-fifth World Health Assembly (A65/14).

iii (2011) Disability and the Millennium Development Goals A Review of the MDG Process and Strategies for Inclusion of Disability Issues in Millennium Development Goal Efforts

iv Waage, J et al (2010) The Millennium Development Goals: a cross-sectoral analysis and principles for goal setting after 2015. The Lancet 2010; 376:991-1023

v Sightsavers (2011) Making Inclusive education and reality. Policy paper

vi www.unesco.org/new/en/education/.../education-for-all/efa-goals/

vii UNESCO. EFA Global Monitoring Report. 2010

viii Sightsavers (2010) Strengthening Eye health: A focus for health systems

ix WHO (2012a) Accelerating work to overcome the global impact of neglected tropical diseases. A roadmap for implementation. WHO Press, Geneva.

x Schweitzer, J Makinen, M Wilson, L and Heymann, M (2012) Post-2012 Health MDGs. Results for Development Institute

xi WHO (2012) Monitoring the achievement of the health-related Millennium Development Goals. Sixty-fifth World Health Assembly (A65/14).

xii Waage, J et al (2010) The Millennium Development Goals: a cross-sectoral analysis and principles for goal setting after 2015. The Lancet 2010; 376:991-1023

xiii UNAIDS, UNICEF, UNFPA, WHO (2012) UN System task team on the Post 2015 UN Development Agenda. Health in the post-2015 development agenda.

xiv WHO (2012b) Monitoring the achievement of the health-related Millennium Development Goals. Sixty-fifth World Health Assembly (A65/14).

xv Waage, J et al (2010) The Millennium Development Goals: a cross-sectoral analysis and principles for goal setting after 2015. The Lancet 2010; 376:991-1023

xvi Waage, J et al (2010) The Millennium Development Goals: a cross-sectoral analysis and principles for goal setting after 2015. The Lancet 2010; 376:991-1023

xvii Kestelyn, P and Cunningham, E (2001) HIV/AIDS and blindness Bulletin of the World Health Organization, 2001, 79 (3)

xviii www.unesco.org/new/en/education/.../education-for-all/efa-goals/

xix UNAIDS, UNICEF, UNFPA, WHO (2012) UN System task team on the Post 2015 UN Development Agenda. Health in the post-2015 development agenda.

For further information on the issues in this briefing or any aspect of Sightsavers’ work please contact Charlie Matthews, Parliamentary Adviser: cmatthews@sightsavers.org