What if we allocated aid $ based on how much damage something does, and whether we know how to fix it?

I usually criticize development wonks who come up with yet another ‘if I ruled the world’ plan for reforming everything without thinking through the issues of politics, power and incentives that will determine which (if any) of their grand schemes gets adopted. But it’s been a hard week, and today I’m taking time out from the grind of political realism to rethink aid policy.

Call it a thought experiment. Suppose we started with a blank sheet of paper, and decided which issues to spend aid money on based on two criteria – a) how much death and destruction does a given issue cause in developing countries, and b) do the rich countries actually know how to reduce the damage? That second bit is important – remember Charles Kenny’s book ‘Getting Better‘, which argues powerfully that since we understand how to improve health and education much better than how to generate jobs and growth, aid should concentrate on the former.

If you followed this exercise, I think you would end up with a radically different aid agenda, with a whole bunch of Cinderella issues coming in from the cold (I’m also taking a break from not mixing metaphors).

Here’s the global death toll (from the new edition of FP2P, c/o indefatigable  number crunching from Richard King).

These are global figures, and I don’t have a breakdown by developed/developing. That would be important on obesity, but on other issues, the majority of impact is clearly in poor countries – alcohol, tobacco and road traffic for example. And they are precisely the areas where the rich countries have lots of experience in reducing the damage. It’s certainly a lot more straightforward than inventing/discovering new vaccines. When researchers put signs in Kenyan minibuses (matatus) urging passengers to criticize reckless driving, injuries and deaths fell by a half (for paper see here).

So how come such subjects are so seldom seen as development issues? Where’s the campaign on booze and fag dumping by large corporations in developing countries? Or international seat belt conventions, backed by technical assistance to help governments ratify and implement? Your thoughts please. Presumably some kind of campaigns exist on all these issues – please send links – but they could be a lot more prominent.

And for the truly wonky/medically inclined here’s a more sophisticated version from the Guardian – Disability Adjusted Life Years, which Claire Melamed and John Appleby reckon could be usefully mainstreamed in development. It shows which causes of global death and disability are up/down from 1990-2010. And if you don’t know what Ischemic or COPD mean, look them up.

Development’s Cinderella? Why does the aid industry ignore disabled people?

This is a guest post from Tim Wainwright, an Exfam (ex-Oxfam) friend who now runs ADD International, an NGO working on disability and development. An edited version appeared yesterday on the Guardian Poverty Matters blog.

It really does puzzle me. Why does so much of mainstream development’s resources, research, campaigning efforts and attention ignore disabled people?

Around 1 in 7 of the world’s population – 1 billion people – are disabled. Few extended families will not have a child, a parent, or a grandparent who is disabled. And disabled people will certainly be a significant proportion of the estimated 300 million plus chronically poor stuck ‘below the line’ even if the MDGs succeed in halving poverty by 2015. This is because disability can trap individuals and their families in poverty – and living in poverty also means you’re far more likely to be born disabled or to become disabled. The figures bear this out: within this group there are staggering levels of unemployment (80-90%), literacy rates as low as 3%, and one of every three children not in school are disabled. This is before we even begin to consider the huge number of people whose lives are affected by disability – such as a child who has to leave school when her father becomes disabled through an accident at work.

Talk to any disabled person about their experiences and they will soon tell you about the assumptions and discrimination they face in all areas of life. Just this week I spoke to Said in Tanzania, a young man who is dealing not only with the problems of visual impairment, but also the fear and rejection of his family and community. As a child his relatives refused to buy him a uniform so he could go to school, telling him ‘You are like a dead person to us’.

It is often these negative attitudes that make it harder for disabled people to access their basic rights and to have a voice within their families and communities – let alone at the policymaking level. Our long experience of working with organizations of disabled people has demonstrated, time and again, the powerful difference that disabled people can make by coming together and challenging the assumptions and discrimination which hold them back. This change is going on at all levels – from the grassroots, where activists like Said seek out other disabled people in the community and mentor them in tackling discrimination and accessing opportunities – to the policymaking level, where national disability movements campaign for disability legislation and practical policies to ensure that legislation is implemented.

This is what disabled people are doing. But where are these issues in the mainstream? The Education MDG (the only MDG using the word ‘inclusive’), has a 100% target of school attendance. Yet many education programmes (including large multidonor trust funds) don’t check if disabled children are being reached by their work.

There are exceptions. Some big donors and INGOs have ‘disability units’ and make grants to disabled people – but might not mention that this makes up a tiny percentage of their overall funding. Some have gone further – many Scandinavian donors have excellent policies, and USAID and AusAID have both prioritised disability in helpful ways – as well as admitting they have a way to go. Prior to its closure this year, World Vision’s disability mainstreaming unit published useful materials. But overall, coverage is very thin.

Disabled people appear to be in the same position in the development debate as women were 20 years ago. Not employed by the development industry, not seen and so not reached. I am not suggesting all development work is now gender-sensitised, but compared to disabled people, women do nowadays at least seem to count, and to be counted.

Disabled women are doubly discriminated against. At ADD International we support disabled women to organise and successfully challenge gender based violence (2-3 times higher than for non-disabled women) or to campaign on education where the 3% levels of literacy sink to the shocking level of 1% for disabled women.

I have heard of people in very senior positions in international development saying ‘we do poverty, not disability’. When I worked in the mainstream, there was a sense of competition between development workers who managed to focus their work on the most remote tribal village, to reach the most excluded minority group. Disabled people, particularly women, are probably the poorest and most excluded group there is – but for some reason don’t seem to attract the same level of attention.

It’s true that disabled people are more likely to be economically inactive; many will have lacked food, clothing or access to education from an early age. But this can be overcome – at ADD we have seen many times over how, with support, disabled people can overcome barriers and establish successful small businesses.

So what is it that stops the vast majority of development professionals thinking about this group of people? Is it possible that most still perceive disabled people as a ‘special interest group’, which organisations may or may not take an interest in? Perhaps women in development were once seen in this way – before an understanding of gender issues became mainstream. Our society might now be less patriarchal but are we still living in an ‘ability-archy’?

My challenge to the mainstream is this: Would it be so difficult to put women and disabled people at the heart of everything you do? Employ representative numbers of disabled people in your teams? Make all your offices accessible? Ensure your development work involves and benefits disabled people equally?

Many people think this would cost the earth – but it doesn’t – WaterAid recently published the results of a study in Ethiopia showing that delivering water and sanitation in an accessible way only costs 2-3% more.

I have spent many years working in mainstream development. I now run a disability focussed organisation, and can tell you truthfully that I have never been so inspired by what a particularly challenged group of people are able to achieve, when they are empowered to organise, form self help groups, understand their rights, and have the opportunity to take control of their own lives. I don’t believe disabled people need a non-disabled Prince Charming – they just need an invitation to the ball.

And here’s a 14 minute ADD video to back up Tim’s arguments:

Advocacy v Service Delivery in Russia: FP2P flashback

Next up in this holiday week selection of largely unread posts from the early days of the blog, a story from Russia

Contrasting case studies from Oxfam GB’s Russia programme, which has tried different ways of supporting Russia’s estimated 5.6 million disabled people. Traditionally, we have run a microfinance programme which has benefited a total of 40,000 people – 5,500 recipients plus other beneficiaries, such as family members. Total expenditure to date some £2m ($3.1m and falling…..). Recently, however, we tried something different – advocacy.

Up until this year, disabled people in Russia had to register every year in order to be entitled to work and to receive benefits from the Russian government. This proved to be both time consuming (up to six months of every year), humiliating and sometimes ridiculous. Someone with an amputated leg had to prove every year that the leg had not magically grown back over the intervening twelve months. And only then would it be possible to get entitlement to benefits.

Natalia, the leader of a self help group for disabled people in Russia, supported by Oxfam, told us what this meant for her, “I am permanently disabled, and yet every year I have to go through a six month process to prove to the government that I am disabled – this process is humiliating and tiring. You go back and forth and back and forth to the doctors and go through so much bureaucracy. I am young and fit so I am able to do this process but imagine if you are a pensioner in an isolated village – it is impossible. Those who have been injured and have lost limbs, still have to prove every year that they are disabled – it is a degrading system!”

Working with the Global Call to Action on Poverty (GCAP) coalition in Russia, Oxfam staffer Vitaliy Kartamyshev included the issue of registration for disabled people in a more wide-ranging report on healthcare in Russia. The report proposed a change to the regulation so that people who are permanently disabled only have to register once in their lives.

In March 2008 the report was launched at a national press conference. This was followed by intensive lobbying of senior government officials at the Ministry of Health and the parliament (Duma). The regulation № 247 on “introducing changes in the rules of recognizing disability” was passed on April 7, 2008 by the Ministry of Health . The government adopted the precise change in regulation concerning disabled people proposed by GCAP.

Total cost of the campaign, in terms of Oxfam spending? About £100,000 ($155,000). This change will affect tens of thousands of people, including an unknown number that have simply given up registering because of the hassle, and may now be persuaded to claim benefits.

It’s hard to compare the two approaches – service delivery is pleasingly concrete, and so it is easier to assess its impact. Advocacy work often suffers from issues of attribution (did the Russian government change its law because of the campaign, or would it have done so anyway?) and impact (how do you measure the impact on people’s wellbeing of not having to waste six months a year wrangling with officialdom?) Advocacy more closely resembles a venture capitalist approach – of ten such campaigns, maybe only one or two will achieve their aims, but they will ‘win big’, whereas service delivery appeals more to the predictable world of logframes and planners. What’s clear from this example, though, is that both have their place in the NGO armoury, which is why, over time, advocacy has become more significant in Oxfam and other NGOs’ work (though it still remains a small proportion of the total spend).

This post was first published in October 2008

The first ever World Disability Report – what took them so long?

North-South convergence is undeniable (and a bit of a development cliche), but it’s not just about economies or political power. There’s also a growing recognition that social issues look increasingly similar across the North-South divide. Similar, but not identical – obesity may be on the rise in countries like Mexico and South Africa, but there, it coexists with hunger and malnutrition. Other issues that are bound to rise up the development agenda, especially if income poverty continues to fall, include mental health, ageing, reproductive rights, or discrimination on the basis of sexuality (think of the recent controversies over gay and lesbian rights in various African countries). They will join other social issues around gender, ethnicity or religion that have long been recognized as relevant to the development debate.

Another such topic is disability – most people who have travelled much will have been struck by both the number of people with disabilities in poor countries, and how often they are ignored, locked away or maltreated.  But somehow this often failed to make it onto our priority list. Until now. The first ever World Report on Disability was published yesterday by the WHO and World Bank. Some highlights:

There has been a paradigm shift in approaches to disability. In recent decades the move has been away from a medical understanding towards a social understanding. Disability arises from the interaction between people with a health condition and their environment. The emphasis should be on removing environmental barriers which prevent inclusion.

There are over one billion people with disabilities in the world, of whom between 110-190 million experience very significant difficulties. This corresponds to about 15% of the world’s population and is higher than previous World Health Organization (WHO) estimates, which date from the 1970s and suggested a figure of around 10%. [did you get that? The first estimate in 40 years – now that’s what I call neglect].

The prevalence of disability is growing due to population ageing and the global increase in chronic health conditions. Patterns of disability in a particular country are influenced by trends in health conditions and trends in environmental and other factors – such as road traffic crashes, natural disasters, conflict, diet and substance abuse.

Disability is more common among women, older people and households that are poor. Lower income countries have a higher prevalence of disability than higher income countries. According to the Guardian’s coverage of the launch, 20% of the world’s poorest people have disabilities and nearly 80% of people with disabilities live in low-income countries.

The  recommendations are based on the United Nations Convention on the Rights of persons with Disabilities (CRPD) and are pretty much what you would expect – governments need to spend more, have a national disability strategy and plan of action etc. The report talks about involving and consulting people with disabilities, but I didn’t see anything on supporting them to organize independently, at least in the summary materials, which is a worrying omission.

Possible wider implications for development agencies? Get out of your development comfort zone, look at the issues that are salient in the rich countries and try to understand them better, because albeit in slightly different forms, they are coming our way. We can get a headstart by supporting organizations and states in developing countries to learn about and adapt approaches in the rich countries, rather than starting from scratch.

And here’s one story from the billion – a powerful video about wheelchair users in Tanzania