Disability and development - International Development Committee Contents


6  Treatment and prevention of disabling conditions

67. As we noted earlier, disability is not a purely medical issue, but is instead characterised by discrimination towards disabled people. Most of this report therefore focuses on increasing disabled people's equal access to programmes across the whole of DFID'sportfolio—rather than on treating or preventing medical conditions. Nonetheless, we received powerful evidence that - if DFID is to minimise the adverse impact of disability on development—it is essential to consider treatment and prevention issues too.

The impact of treatment and prevention programmes

68. For the purposes of this report, we use 'treatment' to cover a wide range of healthcare programmes that address disabling conditions—from surgery through to rehabilitation.[206] The direct impacts of such treatment and prevention are powerful—whether surgery that restores sight, provision of artificial limbs that enable people to walk, or the administration of life-changing psychiatric therapy. As highlighted in a recent report by Save the Children, access to better basic healthcare at birth can prevent an entire lifetime of disability.[207] Sometimes, treatment for disabling conditions can be a matter of life and death. One of our witnesses told us:

    I became spinal­cord­injured in 2008. In a low­income country, I would most likely be dead by now, not because I needed life­saving surgery or anything, but because I needed catheters and I needed to avoid pressure sores. It is those very basic things from which many, many people die and which reduce life expectancy.[208]

69. Moreover, witnesses emphasised that besides its direct health benefits, treatment of disabling conditions also has important indirect impacts. It can enable people to access other rights such as education, and to participate more fully in their communities.[209] One submission described the benefits of a rehabilitation programme providing mobility devices:

    When I am on my tricycle, I don't feel at all like a disabled person. This tricycle makes me forget my disability. It is my aeroplane that flies me to every destination.[210]

Access to community-based rehabilitation and care services can also save children from being placed in institutions, which, as evidence from Lumos highlighted, can have devastating consequences for their safety and long-term psychological well-being.[211]

70. For people with mental health problems, treatment can sometimes make the difference between freedom and imprisonment. On our visit to Burma, we saw first-hand how a family had resorted to tying up their son, who had a mental health problem, to stop him harming himself. In Indonesia alone, a recent estimate suggested that 18,000 people with mental health problems are kept in chains.[212]

71. In addition, treatment and prevention of disabling conditions can have an indirect economic impact.For example, a recent study for the World Economic Forum suggested the global economy would lose $16 trillion due to mental illness over the next 20 years.[213] . By preventing or treating disabling conditions, donors can achieve substantial development gains: for instance, research in India estimated every $1 spentin treating Neglected Tropical Diseases (Box 5) yields a return of $20 to $30.[214]Box 5 Two Significant Causes of Disability: Neglected Tropical Diseases and Non-Communicable Diseases
Neglected Tropical Diseases (NTDs) are a group of infectious conditions that thrive in hot, humid conditions. Examples causing disability include:

-  Trachoma—causes blindness

-  Leishmaniasis—an infection transmitted by sandflies that causes death or disfigurement

-  Lymphatic Filariasis—causes severe, disabling, swelling of lower parts of the body

-  Schistosomiasis—causes learning difficulties in children, and ultimately also organ damage

-  Soil transmitted helminths—can lead to chronic weakness and to intellectual disability[215]

Non-Communicable Diseases (NCDs) comprise:[216]

-  Cancer

-  Cardiovascular condition

-  Diabetes

-  Chronic respiratory conditions

Non-Communicable Diseases frequently lead todisability: for example, it is thought that one person undergoes an amputation every 20 seconds due to diabetes.[217]

Unmet need for treatment and prevention

72. Our evidence showed that, in developing countries, treatment and prevention for many disabling conditions is extremely scarce: Table 3 illustrates the scale of unmet need, and Figure 1 shows, in particular, the shortage of funding for mental health care in low income countries.
Table 3 Treatment and prevention of disabling conditions - unmet needs
Rehabilitation -  70 million people worldwide need a wheelchair: only 515% have access to one.[218]

-  Less than 3% of the hearing aid needs in developing countries are met annually (estimated by hearing aid producers)[219]

-  In many low-income countries, there is statistically less than one physiotherapist forthe entire population.[220]

Mental health care -  Funding for mental health services in developing countries is extremely limited (Figure 1)

-  Only around 10% of people with mental health problems in low and middle income countries receive the treatment they need: in Nigeria the figure is as low as 2%.[221]

Dementia -  It is estimated that 135 million people will be living with dementia by 2050—70% of them in developing countries.[222] The scale of the problem is such that the Prime Minister has called for it to be "at the heart of the development agenda".[223]

-  The unmet need for care is hard to quantify, but is likely to be particularly acute in low and middle income settings.[224]

Neglected Tropical Diseases -  The proportion of people receiving the medical assistance they need is very low for most NTDs—e.g. only around 13% for trachoma[225]

-  Interventions tend to focus on disease prevention rather than treatment—yet treatment can stop people being disabled for life.[226]

Non-Communicable Diseases -  NCDs account forover 10% of all years lived with disability in low-income countries.[227]

-  The Global Status Report on NCDs found a third of low-income countries have no funding for NCD prevention and control.[228]  

Neonatal health care -  Over 2% of years lived with disability in low-income countries are due to neo-natal conditions.[229]

-  The presence of a skilled attendant substantially reduces the risk of death and disabling conditions for newborns, yet every year, 40 million women give birth without a skilled attendant, and 2 million give birth completely alone.[230]

Figure 1: Mental Health Spending Variations

Source World Health Organisation, Investing in Mental Health: Evidence for Action, Geneva, 2013, p.15

Cost-effectiveness of treatment and prevention

73. An emerging evidence base suggests many treatment and prevention measures meet international cost-effectiveness benchmarks. Commonly, treatments are considered very cost-effective if the cost for an extra year of healthy life is less than the average annual per capita Gross Domestic Product of the country in question (this is broadly similar to the approach that NICE uses in the UK).[231] The following measures all fall comfortably within this threshold:

·  Many responses to Neglected Tropical Diseases—these are often extremely inexpensive (some cost just a few pounds per healthy year saved)[232]

·  Treatment and rehabilitation for deaf people (e.g. treating ear infections; screening and providing hearing aids)[233]

·  Surgery for trachoma and cataracts, provision of spectacles for people with refractive errors[234]

·  Treatment for epilepsy and depression[235]

·  A range of measures to tackle cancer and cardiovascular disease[236]

·  A range of interventions to improve newborn health, for example, the presence of skilled birth attendants.[237]

74. Less data exists for some treatment and prevention measures—in particular, we have not seen any detailed analysis on the cost-effectiveness of wheelchair provision, or of basic care for conditions such as spinal cord injuries. However, anecdotal evidence to the inquiry repeatedly indicated such measures could often achieve substantial impacts for very low costs.[238] This is particularly true of community-based rehabilitation, which our witnessessaid can bea low-cost way to reach large numbers of people in remote locations, especially when integrated in wider work to strengthen health systems.[239] One witness told us of a community based rehabilitation programme that had halved the mortality rate for children with spina bifida in one area of Uganda.[240] Electronic technologies increasingly offer another route to reach many people relatively cheaply.[241]

75. There may also be opportunities for DFID to secure improvements in cost-effectiveness—particularly in the case of assistive devices such as wheelchairs and hearing aids. International guidance such as the WHO's Guidelines on the Provision of Manual Wheelchairs in Less Resourced Settings—suggests several ways to obtain such devices at low cost. One is to develop local production capacity. Another is to buy in bulk—although it is important to ensure that the devices are suitable for the local context; accompanied with facilities for training and repair; and procured as part of a sustainable plan for strengthening rehabilitation services in-country, including local production.[242] USAID is already working to provide more assistive devices, so there may be opportunities to join forces.[243] When we questioned the Minister about opportunities to buy in bulk, she countered that manufacturers might be willing to offer devices free in order to develop overseas markets.[244]However we are sceptical that this will happen quickly, widely, or sustainably, enough to meet the scale of global demand.

DFID's current treatment and prevention work

76. DFID is already taking some welcome steps to help treat or prevent the conditions that cause disability.This includes:

·  Rehabilitation: funding a diverse range of programmes, e.g. the International Committee of the Red Cross (rehabilitation in conflict settings); Motivation (mobility impairments); Sightsavers and Vision Aid (visual impairments); Interburns; and Healthprom (early years care for a variety of disabilities, in order to reduce institutionalisation).[245]

·  Mental health treatment—primarily through two innovative programmes:

—  The PRIME research programme, which aims to put cost-effective treatments into practice, in partnership with ministries of health in South Africa, Uganda, Ethiopia, India and Nepal.[246] The programme budget is £6 million over six years.[247]

—  Support to the NGO BasicNeeds in Ghana and India. Theprogramme encompasses treatment, access to basic services, and empowerment. The programme budget is around £2.5 million over 7 years (Ghana) and £500,000 over 4 years (India).[248] DFID is also funding the Ghanaian Government to strengthen mental health services.[249]

DFID stands out as one of the only international donors to work on mental health.[250]

·  Prevention. These programmes include a £50 million programme to tackle blinding trachoma (2012-2018), and a £31 million programme to eliminate lymphatic filariasis (2009-2017).[251] More widely, many of DFID's healthcare programmes contribute to disability prevention, among other objectives—for example, its maternal health programmes reduce the risk of conditions such as fistula;[252]its neonatal health work helps prevent disabilities resulting from complications at birth; and it is working to eradicate or control several conditions such as polio, measles, and rubella that cause both death and disability.[253]

·  Health system strengthening—this aims, among other goals, to help partner countries prevent the onset of Non-Communicable Diseases.[254]

77. These programmes are valuable—but they represent a very small share of DFID's overall health budget. For example, DFID's evidence to the inquiry suggests it spends less than 1% of its total budget on Neglected Tropical Diseases, and less still on mental health.[255]In addition, the geographic coverage of DFID's mental health work is limited: a mental health service users' group from Kenya wrote to us highlighting the shortage of international support for mental health in their country.[256]

DFID's approach to prioritising its health portfolio

78. Even when interventions meet international cost-effectiveness standards, DFID cannot fund them all, and must make tough choices. DFID last undertook a full review of its health portfolio in 2009, and made further revisions as part of the Bilateral Aid review in 2011. These reviews worked on a country-by-country basis, and took into account factors such as the following:[257]

·  International guidelines on the cost-effectiveness of different interventions in low-resourced settings, primarily the World Health Organisation's CHOICE guidelines.[258]

·  The Millennium Development Goals, which place particular emphasis on nutrition (MDG 1), maternal and neo-natal health (MDG 4 and 5), and HIV/AIDS, malaria and TB (MDG 6).

·  The priorities of country governments.

·  The work of other donors.

79. We are pleased that, in choosing how to spend its health budget, DFID takes into account a range of important factors, particularly international guidelines on cost-effectiveness. However, we are concerned that DFID's approach to health spending may under-state the importance of treating and preventing the conditions that lead to disability. A full review of DFID's approach to prioritising health programmesis outside the scope of this report, but we have a number of specific concerns:

·  International cost-effectiveness guidelines focus on health outcomes.They do not consider broader impacts, for example on an individual's human rights and access to services.[259] In the case of disabling conditions, these impacts are often particularly severe (Table 1, Box 3, paragraphs 7, 11, 69, 70)

·  International cost-effectiveness guidelines focus on specific conditions in isolation. They do not allow for the fact that disabling conditions tend to lead tofurther health complications—for example, people suffering from Neglected Tropical Diseases (NTDs), Non-Communicable Diseases (NCDs), or HIV/AIDS are more likely to develop mental health problems—and vice versa.[260]

·  Experts have pointed out a number of technical difficulties in the definition of the cost of an additional year of healthy life, in practice, are likely to undervalue interventions that tackle disability.[261]

·  Cost-effectiveness data is only available for a limited number of conditions, which risks skewing the analysis: for example, the WHO's CHOICE guidelines do not cover the effectiveness of some forms of rehabilitation (e.g. provision of wheelchairs or basic care); of most types of NTD prevention; or of ways to manage dementia.[262]

80. We recommend DFID issue a guidance note to clarify that, in making difficult decisions on health spending, it is important to look beyond narrow measures of cost-effectiveness.The value of programmes that treat and prevent disabling conditions lies not only in their medical impact, but also in their ability to increase people's opportunities and potentially lift them out of poverty.While we were not in a position to do a full cost-benefit analysis of DFID's health programmes, we have seen some persuasive evidence that DFID should increase its spending on disability treatment and prevention. We recommend DFID thoroughly appraise the case for spending more in the following areas. If DFID decides not to increase its spending, it should explain its reasons to the Committee.

·  Mental health care

·  Rehabilitation and basic care, e.g. for people with spinal cord injuries

·  Provision of assistive devices, potentially joining forces with USAID or other major donors to buy in bulk

·  Neglected Tropical Diseases

·  Non-Communicable Diseases

·  Newborn Health

We also recommend DFID gather detailed data on the cost and impact of all its treatment and prevention work, so as to improve the international evidence base on cost-effectiveness.

81. Specifically on dementia, DFID told us that it was awaiting guidance from the Department of Health—the lead department—before embarking on further programming.[263] The evidence base on dementia is less extensive than for some other causes of disability, but the submission from Alzheimer's International pointed to several steps that the UK could already take—funding research; building developing countries' capacity to respond to dementia; and tackling stigma.[264]Dementia is a growing cause of disability in developing countries, and the Prime Minister has called for it to be "at the heart of the development agenda":[265]we urgeDFID and the Department of Health to update the Committee on their plans to accomplish this.

Preventative measures outside the health sector

82. Causes of disabling injuries are extremely diverse,[266] and a complete assessment was outside the scope of this inquiry. Nonetheless, we did receive evidence on somecommon causes of disabling injuries, and steps that DFID can take to help prevent them.

ROAD SAFETY

83. Road traffic accidents leave tens of millions of people injured or disabled every year.[267] Safely designed roads, with footpaths, cycle lanes, and safe crossings, not only help prevent disability, but also make access easier for road users who are already disabled. Our 2011 report, DFID's Role in Building Infrastructure in Developing Countries, found that:

    The multilateral development banks are responsible for the overwhelming majority of donor-funded road-building projects in developing countries. MDB-funded roads should be designed with safety as a paramount concern. DFID should work harder to ensure that road safety design is an essential part of the multilateral road-building projects it funds. We agree with the Global Road Safety Partnership that, when making decisions to invest in infrastructure, DFID should make a life-cycle risk analysis of the expected road crash death and injury scenarios that can be expected, and then require stipulations to be put in place to manage these risks as part of the funding packages.[268]

    Our report also recommended that DFID reinstate a pledge to provide £1.5 million funding to the Global Road Safety Facility (GRSF).[269]

84. In response to our report, DFID reinstated its donation to the GRSF. It says it has used its position as a GRSF board member to press for a greater emphasis on road safety in World Bank programmes, and those of other multilateral development banks.DFID says the World Bank has recently approved a policy that it will only approve lending to programmes that address road safety.[270]We welcome DFID's response tothe recommendations on road safety in our 2011 report on DFID's Role in Building Infrastructure in Developing Countries. We also welcomethe news that the World Bank will only approve loans to programmes that address road safety.DFID should keep up the pressure on the World Bank to meet its road safety commitments, requiring that all newprogrammes are supported by a full life-cycle risk analysis, and by monitoring mechanisms to ensure risks are successfully mitigated. We also recommend that itrequireother multilateral development partners—including development banks and the European Union— to introduce similar road safety policies, as a condition of future UK funding.

ARMED VIOLENCE

85. Handicap International's submission draws attention to the large number of disabilities that result from armed violence: it reports that an estimated two million people live with firearms injuries sustained in non-conflict settings over the past decade.[271] The World Health Organisation says that some groups at risk of violence receive little attention from donors—for example, young men are particularly at risk of armed violence; and violence against older people also tends to be neglected(1 in 20 older people suffer abuse).[272]Given the links between armed violence and disability, we welcome DFID's research programme on urban violence in developing countries—the Safe and Inclusive Cities programme (£4.5 million, 2012-2017).[273]We recommend DFID develop further programmes to tackle armed violence, and target all groups at risk of violence, including young men and older people.


206   In this report, we use 'rehabilitation' to mean measures that help people with impairments to"achieve and maintain optimal functioning in interaction with their environments" (World Report on Disability). Examples include advice on self-care; and the provision of assistive devices such as wheelchairs and hearing aids. Back

207   Save the Children, Surviving the First Day: State of the World's Mothers, 2013 Back

208   Q86 [Dr Shakespeare] Back

209   For example, Nepal National Association of Service Providers of Physical Rehabilitation (DIS0016) para 2, AbleChild Africa (DIS0026) para 2.3.2, Motivation (DIS0017) paras 2,4,5,6,10, David Constantine MBE (DIS0087), BasicNeeds (DIS0064) para 3.1 Back

210   Motivation (DIS0017) para 6 Back

211   It is estimated that 8 million children worldwide live in some form of institution. The risks include impaired brain development, mental health problems, and abuse: Lumos (DIS0029) paras 1.3, 2.2.1, 4.3. Back

212   Centre for Global Mental Health (DIS0052) para 2.1.2 Back

213   World Economic Forum and Harvard School of Public Health, The Global Burden of Non-Communicable Diseases, Geneva, 2011, p29 Back

214   Chu BK and colleagues, 'The Economic Benefits Resulting from the First Eight Years of the Global Programme to Eliminate Lymphatic Filiariasis (2000-2007), PLOS Neglected Tropical Diseases, 2010.  Back

215   UK Coalition against Neglected Tropical Diseases, Annual Report 2012, pp 9-10 Back

216   World Health Organisation, Global status report on noncommunicable diseases 2010, Geneva Back

217   Q78 [Ms Shivji]. See also Age International Annex A (DIS00104). Back

218   World Health Organisation, 'Governments to agree increased focus on people with disabilities in development strategies', 20 September 2013, accessed 28 March 2014 Back

219   World Health Organisation/World Bank, World Report on Disability,Geneva, 2011, p102 Back

220   Q88 [Dr Shakespeare]  Back

221   Q86 [Prof Thornicroft] Back

222   Alzheimer's Society and Alzheimer's Disease International (DIS0035) para 2.1 Back

223   Alzheimer's Society and Alzheimer's Disease International (DIS0035) para 3 Back

224   World Health Organisation and Alzheimer's Disease International, Dementia: A Public Health Priority, 2012, Geneva, pp 39, 50, 52, 55, 56 Back

225   UK Coalition against Neglected Tropical Diseases, Annual Report 2012, pp 9-10 Back

226   NTDs: Disease Control is about Much More than Drugs, The Guardian, 9 January 2014.  Back

227   World Health Organisation, 'Regional Estimates for 2000-2011', YLL Estimates: World Bank Income Groups, accessed 29 March 2014  Back

228   World Health Organisation, Global Status Report on Non-Communicable Diseases 2010, Geneva, p73 Back

229   World Health Organisation, 'Regional Estimates for 2000-2011', YLL Estimates: World Bank Income Groups, accessed 1 April 2014 Back

230   Save the Children, Surviving the First Day: State of the World's Mothers, 2013, p40. Back

231   D Chisholm and colleagues, What are the Priorities for the Prevention and Control of Non-Communicable Diseases and Injuries in Sub-Saharan Africa and South-East Asia, British Medical Journal 2012;344:e586. Back

232   World Health Organisation, Working to Overcome the Impact of Neglected Tropical Diseases: First WHO Report on Neglected Tropical Diseases, Geneva, 2010, p18 18 Back

233   D Chisholm and colleagues, What are the Priorities for the Prevention and Control of Non-Communicable Diseases and Injuries in Sub-Saharan Africa and South-East Asia, British Medical Journal 2012;344:e586. Back

234   As above Back

235   As above Back

236   As above Back

237   T Adam and Colleagues, Cost effectiveness analysis of strategies for maternal and neonatal health in developing countries, BMJ, 2005;331:1107. Back

238   Q100 [Dr Shakespeare] Back

239   Q100 [Dr Shakespeare and Prof Groce]. Integration in wider community health systems both helps ensure sustainability [Prof Groce] and helps reduce stigma (agreed minute of informal meeting with the Centre for Global Mental Health) Back

240   Q95 [Dr Shakespeare] Back

241   WHO/World Bank, World Report on Disability,Geneva, 2011, pp118-119 Back

242   WHO, Guidelines on the Provision of Manual Wheelchairs in Less Resourced Settings, Geneva, 2008, pp 40, 45, 117, 120. WHO/World Bank, World Report on Disability, Geneva, 2011, para 117-118. See also Soundseekers Annex A (DIS0107) for similar considerations with respect to hearing aids. Back

243   USAID (DIS0088) para 9 Back

244   Q191 Back

245   DFID (DIS0054) para 41, DFID Annex B (DIS0071) Back

246   Centre for Global Mental Health Back

247   DFID (DIS0054) para 44, DFID Annex B (DIS0071) Back

248   DFID Annex B (DIS0071), Basic Needs (DIS0064) paras 2.1, 3.1 and 3.3. DFID also supports some smaller mental health programmes, for example a £76,000 programme with a local civil society organisation in Ghana (see for example DFID Annex B, DIS0071). Back

249   DFID, 'Ghana Health Sector Support Programme 2012-2018', accessed 25 March 2014 Back

250   Agreed minute of informal meeting with Jagannath Lamichhane and Dr Mary de Silva, 30 January 2014 Back

251   DFID Annex B (DIS0071) Back

252   A hole in the birth canal which, if untreated, leads to severe discomfort and often intense stigma and isolation. Back

253   DFID (DIS0054) para 36, DFID Annex B (DIS0071), DFID, 'Development Tracker: Population Policies/Programmes and Reproductive Health', accessed 1 April 2014. Back

254   DFID Health Position Paper: Delivering Health Results, 2013, p20 Back

255   DFID Annex B (DIS0071), 213-14 data. Total health budget taken from DFID's Development Tracker - Aid by Sector, accessed 26 March 2014 [final 2013-14 result may change as additional health funding is allocated, but this is unlikely to be material]. Save the Children also highlight that, while DFID's spending on maternal, newborn and reproductive health is substantial, only a small proportion of this funding is devoted to newborn care (Surviving the First Day: State of the World's Mothers, 2013, p53). Back

256   Users and Survivors of Psychiatry in Kenya (DIS0078) paras 2, 5, 8 Back

257   DFID Annex D (DIS0092) paras 26 and 27, DFID Health Portfolio Review Report 2009, p 6,7,16,17,18,30. DFID Bilateral Aid Review in Health guidance: How to Estimate the Costs and Benefits of Health Related Activities, p 1,2,5.  Back

258   CHOosing Interventions that are Cost Effective, 'WHO-CHOICE', accessed 29 March 2014. . The CHOICE guidelines' message on measures to treat and prevent disability is complex. While many such treatment and prevention measures fall within the CHOICE cost-effectiveness threshold, fewer make the list of very best buys: for instance, treatments for conditions such as mental health and non-communicable diseases tend often to be more expensive than those for some common infectious diseases. Back

259   D Chisholm and colleagues, What are the Priorities for the Prevention and Control of Non-Communicable Diseases and Injuries in Sub-Saharan Africa and South-East Asia, British Medical Journal 2012;344:e586.  Back

260   NTDs: disease control is about much more than drugs, The Guardian, 9 January 2014; Kolappa and colleagues, No Physical Health without Mental Health: Lessons Unlearned?, Bulletin of the World Health Organization2013;91:3-3A; World Health Organisation Executive Board, HIV/AIDS and Mental Health: Report by the Secretariat, 2008. Back

261   Arnesen and Nord, The Value of DALY Life: Problems with Ethics and Validity of Disability Adjusted Life Years, British Medical Journal 1999, 319:1423. For example, some versions of the calculation give less weight to conditions affecting older people. Back

262   CHOosing Interventions that are Cost Effective, 'WHO-CHOICE', accessed 29 March 2014 Back

263   Q190 Back

264   Alzheimer's Disease International (DIS0035) paras 4.1, 4.2, 4.6, 4.8 Back

265   Alzheimer's Society and Alzheimer's Disease International (DIS0035) para 3 Back

266   See for example WHO, Violence and Injury: the Facts, p 3 for common causes of injuries. Back

267   WHO, 'Violence and Injury Prevention: Road Traffic Injuries', accessed 30 March 2014 Back

268   International Development Committee, Ninth Report of Session 2010-12, DFID's Role in Building Infrastructure in Developing Countries, HC 848-I, para 79 Back

269   As above, para 80 Back

270   DFID Annex D (DIS0092) para 28 Back

271   Handicap International (DIS0012) para 3.2. See also World Vision (DIS0023) para 20. Back

272   WHO, Preventing Violence and Reducing its Impact: How Development Agencies Can Help, Geneva, 2008, p25 Back

273   DFID Development Tracker - Safe and Inclusive Cities, accessed 26 March 2014 Back


 
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