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'sportfoliorather than on treating
or preventing medical conditions. Nonetheless, we received powerful
evidence that - if DFID is to minimise the adverse impact of disability
on developmentit 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 conditionsfrom surgery through to
rehabilitation.[206]
The direct impacts of such treatment and prevention are powerfulwhether
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:
- Trachomacauses blindness
- Leishmaniasisan infection transmitted by sandflies that causes death or disfigurement
- Lymphatic Filariasiscauses severe, disabling, swelling of lower parts of the body
- Schistosomiasiscauses learning difficulties in children, and ultimately also organ damage
- Soil transmitted helminthscan 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 205070% 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 NTDse.g. only around 13% for trachoma[225]
- Interventions tend to focus on disease prevention rather than treatmentyet 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 Diseasesthese 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 measuresin 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-effectivenessparticularly
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 Settingssuggests
several ways to obtain such devices at low cost. One is to develop
local production capacity. Another is to buy in bulkalthough
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 treatmentprimarily
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 objectivesfor 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 strengtheningthis
aims, among other goals, to help partner countries prevent the
onset of Non-Communicable Diseases.[254]
77. These programmes are valuablebut
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 complicationsfor example,
people suffering from Neglected Tropical Diseases (NTDs), Non-Communicable
Diseases (NCDs), or HIV/AIDS are more likely to develop mental
health problemsand 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 Healththe
lead departmentbefore 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
takefunding 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 partnersincluding
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 donorsfor 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 countriesthe
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
|