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DFID
Department for
International
Development
Disability, poverty and development
Department for International Development
The Department for International Development (DFID) is the British
government department responsible for promoting
development and the reduction of poverty. The government elected in May 1997
increased its commitment to development
by strengthening the department and increasing its budget.
The policy of the government was set out in the White Paper on International
Development, published in November 1997.
The central focus of the policy is a commitment to the internationally
agreed target to halve the proportion of people living
in extreme poverty by 2015, together with the associated targets including
basic health care provision and universal access
to primary education by the same date.
DFID seeks to work in partnership with governments which are committed to
the international targets, and seeks to work
with business, civil society and the research community to encourage
progress which will help reduce poverty. We also work
with multilateral institutions including the World Bank, United Nations
agencies and the European Commission. The bulk
of our assistance is concentrated on the poorest countries in Asia and
sub-Saharan Africa.
We are also contributing to poverty elimination and sustainable development
in middle income countries, and helping the
transition countries in Central and Eastern Europe to try to ensure that the
widest number of people benefit from the process
of change.
As well as its headquarters in London and East Kilbride, DFID has offices in
New Delhi, Bangkok, Dhaka, Kathmandu,
Nairobi, Dar-es-Salaam, Kampala, Harare, Pretoria, Suva and Bridgetown. In
other parts of the world, DFID works through
staff based in British embassies and high commissions.
DFID – February 2000
i
Disability, poverty and development
Contents Page
Introduction 1
Disability & poverty 2
What is disability?
The International Development Targets
Poverty: a cause & consequence
The costs of disability
Rights & social exclusion
Differential needs
The international framework 6
Approaches and good practice 7
Prevention
The ‘social model’ of disability
Community-based rehabilitation
Areas for action and the role of development co-operation 11
The twin-track approach
Policy
Economic, social and human development
Infrastructure
Conflict and humanitarian assistance
Empowerment
Media and communications
Gaps in knowledge
Measuring progress
Annex: United Nations Standard Rules on the Equalisation of
Opportunities for Persons with Disabilities 16
ii DFID – February 2000
Introduction
Disability is both a cause and consequence of poverty.
Eliminating world poverty is unlikely to be achieved unless
the rights and needs of people with disabilities are taken
into account.
According to the United Nations, one person in 20 has a
disability. More than three out of four of these live in a
developing country1. More often than not they are among
the poorest of the poor. Recent World Bank estimates
suggest they may account for as many as one in five of the
world’s poorest2. Disability limits access to education and
employment, and leads to economic and social exclusion.
Poor people with disabilities are caught in a vicious cycle
of poverty and disability, each being both a cause and a
consequence of the other.
A large proportion of disability is preventable. Achieving
the international development targets for economic, social
and human development will undoubtedly reduce the
levels of disability in many poor countries. However,
general improvements in living conditions will not be
enough. Specific steps are still required, not only for
prevention, but also to ensure that people with disabilities
are able to participate fully in the development process,
obtain a fair share of the benefits, and claim their rights as
full and equal members of society.
An integrated approach is required, linking prevention
and rehabilitation with empowerment strategies and
changes in attitudes. This paper assesses the significance
of disability as a key development issue, and its importance
in relation to poverty, human rights, and the achievement
of internationally agreed development targets. It also
sets out ways in which development co-operation,
including DFID’s own work, can help incorporate the
rights and needs of people with disabilities into the
mainstream of poverty reduction work and the
achievement of human rights.
1E. Helander, Prejudice and Dignity; an introduction to community based
rehabilitation, UNDP, 1992. One in 20 is a conservative estimate, with
some sources
suggesting that as many as one in ten of the world’s population may be
defined as having a disability.
2Ann Elwan, Poverty and Disability; a background paper for the World
Development Report, World Bank, October 1999.
DFID – February 2000
1
Disability & Poverty
What is disability?
Defining disability is complex and controversial. Though
arising from physical or intellectual impairment, disability
has social implications as well as health ones. A full
understanding of disability recognises that it has a powerful
human rights dimension and is often associated with social
exclusion, and increased exposure and vulnerability to
poverty. Disability is the outcome of complex interactions
between the functional limitations arising from a person’s
physical, intellectual, or mental condition and the social
and physical environment. It has multiple dimensions and
is far more than an individual health or medical problem.
On this basis, the working definition of disability adopted
in this paper is ‘long-term impairment leading to social
and economic disadvantages, denial of rights, and limited
opportunities to play an equal part in the life of the
community’.
The International Development Targets
The international community is committed to an agreed
set of development targets, aimed at significantly reducing
poverty and accelerating the pace of economic, social and
human development. These are summarised in Box 1.
The international development targets are directly
relevant to women, men and children with disabilities in
poorer countries. Their needs and rights cannot be fully
addressed unless the underlying causes of poverty are
tackled, unless they are empowered to gain access to
education, health services, a livelihood and participate
fully in social life. Given the high proportion of people
with disabilities among the poor, it is unlikely that these
targets can be properly achieved without specific efforts to
tackle disability.
Poverty: a cause and consequence
Poverty is both a cause and consequence of disability.
Poverty and disability reinforce each other, contributing
to increased vulnerability and exclusion.
The majority of people with disabilities find their situation
affects their chances of going to school, working for a
living, enjoying family life, and participating as equals in
social life. It is estimated that only 2% of people with
disabilities in developing countries have access to
rehabilitation and appropriate basic services3.
Box 1: The International Development Targets
The UK Government is committed to a set of internationally agreed
development targets:
Economic Well-being
• a reduction by one-half in the proportion of people living in extreme
poverty by 2015
Human and Social Development
• universal primary education in all countries by 2015
• demonstrated progress towards gender equality and the empowerment of women
by eliminating gender
disparity in primary and secondary education by 2005
• a reduction by two-thirds in the mortality rates for infants and children
under age five by 2015
• a reduction by three-quarters in maternal mortality by 2015
• access through the primary health care system to reproductive health
services for all individuals
of appropriate ages as soon as possible and no later than the year 2015
Environmental Sustainability and Regeneration
• the implementation of national strategies for sustainable development in
all countries by 2005, so as to
ensure that current trends in the loss of environmental resources are
effectively reversed at both global
and national levels by 2015
3Leandro Despouy, 1993, Human Rights and Disabled Persons (Study
Series 6), Centre for Human Rights Geneva and UN New York.
2 DFID – February 2000
Figure 1: Causes of impairment
13%
20%
20%
Malnutrition 20%
Accident/Trauma/War 16%
Infectious Diseases 11%
Non-Infectious Diseases 20%
Congenital Diseases 20%
Other (including ageing) 13%
16%
20% 11%
Source: UN Figures in Overcoming Obstacles to the Integration of Disabled
People, UNESCO, DAA, March 1995
Poor nutrition, dangerous working and living conditions,
limited access to vaccination programmes, and to health
and maternity care, poor hygiene, bad sanitation,
inadequate information about the causes of impairments,
war and conflict, and natural disasters all cause disability
(see Figure 1). Many of these causes are preventable.
According to estimates by the World Health Organisation
(WHO), as many as 20 million women a year suffer
disability and long-term complications as a result of
pregnancy and childbirth. The most common causes of
motor disability are injuries from accidents on the road, at
home, or the workplace; war and violence, including
landmines; birth trauma; and infectious diseases such as
polio and leprosy. Children are often disabled as a result
of malnutrition.
In turn, disability exacerbates poverty, by increasing
isolation and economic strain, not just for the individual
but often for the affected family as well. Children with
disabilities are more likely to die young, or be neglected,
malnourished and poor. People with disabilities who are
denied education are then unable to find employment,
driving them more deeply into poverty. Breaking out of the
vicious cycle of poverty and disability becomes more and
more difficult (see Figure 2).
The result of the cycle of poverty and disability is that
people with disabilities are usually amongst the poorest of
the poor and their literacy rates are considerably lower that
the rest of the population. Women with disabilities suffer a
double discrimination, both on the grounds of gender and
of impairment; their literacy rates are lower than their male
counterparts. Recent UNESCO studies have suggested
that only 1–2% of children with disabilities in developing
countries receive an education. Boys with disabilities
attend school more frequently than girls with disabilities4.
Studies show that women with disabilities are twice to
three times more likely to be victims of physical and sexual
abuse than women with no disabilities. Their access to
reproductive health care is minimal and as a result they
suffer greater vulnerability to reproductive health
problems. There is a lack of awareness regarding women
with disabilities and reproductive health needs. More often
than not, it is assumed that they do not form part of the
target groups because being disabled is associated with
being sexless.
As many as 50% of disabilities are preventable and directly
linked to poverty. For example, the WHO currently
estimates that worldwide there are 1.5 million blind
children, mainly in Africa and Asia. In developing
countries up to 70% of blindness in children is either
preventable or treatable5. The WHO also estimates that
around 50% of disabling hearing impairment is also
preventable. In 1995 this affected a total of 120 million
people worldwide (including seven million children).
4Loud, Proud and Passionate; Including Women with Disabilities in
International Development Programmes, C. Lewis and S. Sygall (eds.),
MIUSA 1997.
5The Prevention of Childhood Blindness. WHO, Geneva, 1992. The WHO
currently estimates that worldwide there are 110 million people with low
vision
and 45 million blind people (of whom 1.5 million are children), mainly in
Africa and Asia. The main causes of blindness in adults are cataract,
infectious
diseases (trachoma, onchocerciasis, leprosy), diabetes and degenerative
disorders. The main causes in children are corneal scarring (due to vitamin
A
deficiency, measles, trachoma, neonatal conjunctivitis or harmful
traditional eye medicines), cataract, genetic causes, and congenital
abnormalities
(e.g. rubella).
DFID – February 2000
3
Figure 2: Poverty and disability – a vicious cycle
DISABILITY
Denial of opportunities
for economic, social and
human development
Vulnerability
to poverty and
ill-health
Social and cultural
exclusion and stigma
Reduced participation in
decision-making, and denial
of civil and political rights
Poverty
Deficits in economic,
social and cultural
rights
The costs of disability
Disability does not just affect the individual, but impacts
on the whole community. The cost of excluding people
with disabilities from taking an active part in community
life is high and has to be borne by society, particularly those
who take on the burden of care. This exclusion often leads
to losses in productivity and human potential. The UN
estimates that 25% of the entire population is adversely
affected in one way or another as a result of disabilities.
The cost of disability has three components;
disability amount to perhaps four to five times as many;
130 million. …These figures are likely to be great
underestimates’8. An earlier study, in 1989, conservatively
estimated that the aggregate costs of blindness to the
Indian national economy, including a minimal subsistence
allowance for blind people, amounted to approximately
US$4.6 billion per year.
9
Analysis of Tanzanian survey data has revealed that
households with a member who has a disability have a mean
consumption less than 60% of the average (and a headcount
20% greater than average), leading the author to conclude
that disability ‘… is a hidden face of African poverty’.
6
7
• the direct cost of treatment, including the costs of
travel and access;
• the indirect costs to those who are not directly
affected (‘carers’);
• the opportunity costs of income foregone from
incapacity.
According to a study of disability in India, ‘At least 32
million people were likely to be disabled in 1991, and the
lives of their families, those people affected indirectly by
Though to be treated with caution, an indicator that is
frequently used to quantify the burden of disease in a country
or region is the DALY (Disability Adjusted Life Year). This
quantification combines estimates of healthy life years lost
because of premature mortality with those lost as a result of
disability/morbidity. According to World Bank11 estimates,
long-term disabilities were responsible for more than a third
(34%) of DALYs lost worldwide in 1990.
10
6Leandro Despouy, 1993, Human rights and Disabled Persons (Study Series 6),
Centre for Human Rights Geneva and UN New York.
7S. Erb and B. Hariss-White, Adult Disability, Poverty and Downward
Mobility: The Macro and Micro Picture from India; Paper presented to the
Development Studies Association Annual Conference, 13th September 1999,
University of Bath.
8ibid.
9WHO, Fact Sheet No 145, February 1997, WHO Web-site.
10Howard White, Africa Poverty Status Report, Third Draft, SPQ 1999.
111993 World Development Report; ‘Investing in Health’.
4 DFID – February 2000
The direct cost of disability, is usually unequally shared.
The burden of care most often falls on family members,
usually mothers or other female relatives. Caring for a child
with a severe disability further increases the workload of
women living in extreme poverty, and takes valuable time
away from the daily struggle to make a living.
12 The burden
of care also often falls on other children, usually girls, who
may have to miss school to remain at home and care for a
sibling or other relative with a disability.
The benefits of reduced disability and morbidity to the
economy are numerous and include increased productivity,
greater opportunities to obtain better-paying jobs, and
longer working lives.
Rights & Social Exclusion
Differential needs
The needs of people with disabilities differ widely. Children,
older people, women, indigenous people, refugees and
displaced persons, minorities, and mentally-ill people
may all experience disability differently. Some may suffer
a multiple disadvantage as a result of their wider social
or economic status. Even within these categories needs
can differ widely, for example between richer and
poorer women.
The consequences are particularly severe for women with
disabilities who are also subject to social, cultural and
economic disadvantages due to gender discrimination.
Moreover, a woman may become disabled due to an abuse of
her rights. It is estimated that over 100 million girls and
women in more than 28 countries in Africa alone are
disabled as a result of female genital mutilation. The physical
and psychological consequences of these practices range
from mobility difficulties, impaired sexual function and
infertility because of infection, to an increased risk of HIV
infection.
‘Disability [is] a Human Rights issue. So long as
people with disabilities are denied the opportunity
to participate fully in society, no one can claim that
the objectives of the Universal Declaration of
Human Rights have been achieved’
Bengt Lindqvist, UN, Special Rapporteur of the Sub-Commission
on Prevention of Discrimination and Protection of Minorities.
14
In many developing countries women are assigned a low
status, socially, economically and politically. This is
accentuated when disability occurs. Girls and women with
disabilities are left marginalised, neglected and are often
considered a burden.
Children are another vulnerable group. Mortality for
children with disabilities may be as high as 80% in countries
where under-five mortality as a whole has decreased to below
20%. In certain cases there seems to be a ‘weeding out’
15 of
children with disabilities, the ‘missing children’.
13
There is an important and fundamental difference between
disability and other forms of disadvantage. People with
disabilities can only organise themselves to claim their
rights when their additional practical needs, such as for
mobility aids, have been met. People with disabilities have
a right to be included in all aspects of life. In order to fight
for the right to inclusion, people with disabilities need to
live in an environment in which they are empowered.
People with disabilities face numerous barriers in realising
equal opportunities; environmental and access barriers,
legal and institutional barriers, and attitudinal barriers
which cause social exclusion. Social exclusion is often the
hardest barrier to overcome, and is usually associated with
feelings of shame, fear and rejection. Negative stereotypes
are commonly attached to disability. People with
disabilities are often assigned a low social status and in
some cases are considered worthless.
Mental illness imposes a heavy burden in terms of human
suffering, stigmatisation of the mentally ill and their
families, and direct and indirect economic costs. The future
burden is likely to grow over time as a result of an increasing
and ageing global population, and increasing stresses
resulting from social problems and unrest, including
violence, conflict, and natural and other disasters.
12S. Miles, Strengthening Disability and Development Work, BOND
Discussion Paper, Feb. 1999.
13World Disability Report, 1999. This quote echoes the Special Rapporteur’s
predecessor. Leandro Despouy’s 1993 report on the connection between
Human Rights and Disability clearly made the point that there is a close
connection between disability and human rights and that the violations of
the
human rights of persons with disabilities are extensive and severe.
14Overcoming Obstacles to the Integration of Disabled People, UNESCO,
DAA, 1995.
15B. Hariss-White; Presentation to the Development Studies Association
Annual Conference, 13th September 1999, University of Bath.
DFID – February 2000
5
The international framework
International standards for upholding the rights of people
with disabilities are set out in the UN Standard Rules on
the Equalisation of Opportunities for Persons with
Disabilities (see Annex 1). These were adopted by the UN
General Assembly in December 1993. They were
developed on the basis of the experience gained during the
UN Decade Of Disabled Persons (1983-92). Although the
rules are not compulsory, they imply a strong moral
and political commitment on behalf of states to take action
for the equalisation of opportunities for persons with
disabilities.
The 22 rules set out important principles for responsibility,
action and co-operation. They point out areas of decisive
importance for the quality of life and for the achievement
of full participation and equality.
• Preconditions for equal participation:
awarenessraising, medical care, rehabilitation and support
services.
• Target areas for equal participation: accessibility,
education, employment, income maintenance and
social security, family life and personal integrity,
culture, recreation and sports, and religion.
• Implementation measures: information and research,
policy-making and planning, legislation, economic
policies, co-ordination of work, organisations of
persons with disabilities, personnel training, national
monitoring and evaluation of disability programmes
in the implementation of the Standard Rules,
technical and economic co-operation, and
international co-operation.
The Standard Rules offer an instrument for policy making
and action to persons with disabilities and their
organisations, and their purpose is to ensure that all people
with disabilities may exercise the same rights and
responsibilities as other members of society. They draw from other
international agreements which constitute the moral and
political foundation for them.
16 Many international
agreements specifically acknowledge disability as a cause of
poverty and disadvantage, and also make the point that the
same rights are to be enjoyed by persons with disabilities.
A Special Rapporteur has been appointed by the UN to
monitor implementation of the Standard Rules. Regular
progress reports are submitted to meetings of the UN
Economic and Social Commission. These show that
progress is being made, but also suggest that a great deal
more could be done. More effort is clearly required by states
and the international community to give more prominence
to the rights and needs of people with disabilities. The
Standard Rules provide a good framework, but need to be
delivered with more energy and commitment.
16These include the International Bill of Human Rights (1948), the
International Covenant on Economic, Social and Cultural Rights (1966), the
Vocational Rehabilitation and Employment Convention (1983), the Convention
on the Rights of the Child (1989), and the Convention on the
Elimination of Discrimination against Women (1979).
6 DFID – February 2000
Approaches and good practice
There has been a long debate within the disability
movement and among practitioners about what constitutes
good practice. Recently, a shift to a broader framework for
action has occurred, with the widespread recognition of
the social and human rights dimensions of disability.
Whatever the approach, prevention must be a top priority.
This needs to be accompanied with actions which seek to
ensure that people with disabilities are supported in their
efforts to develop their full potential, and to lead productive
and fulfilling lives. As a broad principle, good practice
suggests that this means that change must occur within
society and in the way it views disability. Rather than
people with disabilities having to change to fit society,
society must make room for them and uphold their rights.
Prevention
A large amount of disability is preventable, often through
relatively simple, low cost interventions. The general
improvement of living conditions and standards will itself
reduce the incidence of disability. General improvements
to health services will also bring major benefits, both in
reducing the risks of disability and mitigating its effects
when it occurs. Programmes specifically aimed at reducing
or eliminating specific diseases and conditions can also
have a massive impact.
Worldwide, a large number of health initiatives are under
way which will have a widespread and significant impact
on preventing disability. These include a global
commitment, led by the WHO, to eradicate polio, an
important cause of disability. DFID has made a major
contribution to continuing this work in both Africa and
Asia (see Box 2).
This contribution is part of the broader support DFID is
giving to numerous UN programmes, all of which will
bring benefits in relation to disability. These include
programmes to combat leprosy and river blindness,
improvements to maternal and child health, and support to
family planning services. Work through DFID’s direct
support to country programmes will also help reduce, and
respond to, disability. This work includes efforts to develop
health policies and systems which better serve the needs of
the poor, to increase access and benefits to sexual and
reproductive health services for both women and men, and
to promote safer motherhood.
Improved water supply and sanitation, decreased exposure
to environmental hazards, better nutrition, conflict
prevention, and safer transport are all examples of other
areas where support can help prevent disability.
The ‘social model’ of disability
An increasingly common criticism of traditional
approaches to disability, particularly from people with
disabilities themselves, is that their needs have been
marginalised by being categorised as ‘special’ or ‘different’
from those of the population at large. Conventional
approaches have been criticised for being driven by a
perception that people with disabilities need help to adapt
to society’s demands. This approach runs the risk of
favouring technical or medical solutions that emphasise
difference rather than promote inclusion17.
Box 2: Polio eradication in Africa and India
In 1988 the international community set itself the goal of eradicating polio
by the year 2000. This objective
was enshrined in the Global Polio Eradication Declaration, made at the World
Health Assembly. In the year the
declaration was made there were an estimated 350,000 cases of the disease
around the world. By 1999 this
had been reduced to only 5,000.
DFID has been a major supporter of this programme, and in 1999 pledged a
contribution of £60 million over
a two-year period to help finish the job in Africa and Asia.
The eradication of polio will not only contribute to the achievement of
international development targets for
poverty reduction and child health, but lessons learnt from polio
eradication efforts will positively affect routine
immunisation services and help ensure access to these services for all.
17S. Miles, Strengthening Disability and Development Work, BOND
Discussion Paper, Feb. 1999.
DFID – February 2000
7
Recently, however, there have been changes in attitude,
emphasising what is often termed a ‘social model’ of
disability. This places the emphasis on promoting social
change that empowers and incorporates the experiences of
people with disabilities, asking society itself to adapt.
There is increasing recognition that the term disability
does not simply express a medical condition but a complex
system of social restrictions emanating from
discrimination. Empowerment, participation and equal
control become the means of overcoming a disability,
rather than medical care alone.
Cross-cultural differences in the interpretation of disability
show that the lives of people with disabilities are made
more difficult not so much by their specific impairment as
by the way society interprets and reacts to disability.
The social model of disability identifies three major types
of discrimination:
Institutional discrimination exists, for example, where no
legal or other provision is made to ensure that children
with a disability can attend school. Environmental
discrimination is where a person with a disability is
unable to participate due to a physical barrier, such as
inaccessible public transport or inappropriately designed
buildings. Attitudinal discrimination is often expressed
through fear and embarrassment on the part of a
nondisabled person when confronted with a person with a
disability. Also, low expectations of people with disabilities
are discriminatory and undermine the confidence and
aspirations of people with disabilities themselves.
Good practice is most likely to be ensured through an
integrated approach, using best practice in both social and
medical terms. The key to ensure the best use of scarce
resources is to listen to people with disabilities and to take
full account of their views in making decisions, as well as
tackling negative attitudes in society as a whole. Examples
of the adoption of this approach, in both
nongovernmental organisation (NGO) and government
policy, are shown in the Box 3.
18
• institutional discrimination;
• environmental discrimination; and
• attitudinal discrimination.
Box 3: Good practice in NGO and government policy
NGO policy
The Swedish Disabled International Aid Association (SHIA)
promotes a rights-based approach to sustainable
development for persons with disabilities through an emphasis on satisfying
five basic principles:
1. Social Protection: People with disabilities should have
access to basic social protection, defined as housing,
health care, rehabilitation services and access devices.
19
2. Accessibility: People with disabilities should have access
to education, credit, information, and income
earning opportunities.
3. Consciousness: People with disabilities are conscious of
their own needs and rights. They are aware of the
consequences of neglecting and discriminating attitudes in the society.
4. Influence: People with disabilities are entitled to have
equal opportunities to influence decision and policy
making through processes of participation.
5. Control: People with disabilities are entitled to take
initiatives to assert their influence, and promote
awareness of their rights. This enables increased control over the
distribution of resources and benefits.
SHIA seeks to advance these principles through support to the development
and strengthening of organisations
of disabled people in developing countries. It prioritises programmes that
enable people with disabilities to speak
for themselves and which, in turn, strengthen their human rights.
18Beverly Ashton, A Rights Based Approach to Disability, Development and
the Intergenerational Bargain, Paper presented to the DSA Annual
Conference,
Bath, 13th Sept. 1999.
19These include artificial limbs, wheelchairs, hearing aids, braille
machines, and so on.
8 DFID – February 2000
Government policy
The post-Apartheid government in South Africa has published a
comprehensive White Paper, putting forward an
Integrated National Disability Strategy. This is based on the social model
of disability and supports a rights-based
approach. Government departments and State bodies have a responsibility to
ensure that, in each line function,
concrete steps are taken to ensure that people with disabilities are able to
access the same fundamental rights
and responsibilities as any other South African.
To co-ordinate this activity, the Office on the Status of Disabled Persons
has been established in the Office of
the Deputy President. This is charged with working together, and in
parallel, with the various State bodies and
departments and organisations in civil society to further the development of
a disability friendly environment.
In Uganda20, people with disabilities have achieved a greater level
of political representation than in any
other country. The disability movement has begun to have a real impact on
the political scene. The new
constitution provides for the representation of the disability movement at
all levels of political administration. At
parliamentary level five seats are reserved for people with disabilities,
representing the four regions of Uganda
and the interests of women with disabilities. In each local election, at all
levels of government, there must be at
least one representative who has a disability.
Community-based Rehabilitation
Community-based Rehabilitation (CBR) is an approach
which has grown out of the debate between the so-called
medical and social models of disability. Its supporters
believe that it can meet the basic rehabilitation needs of
four out of five people with a disability. CBR attempts to
combine physical rehabilitation through medical care with
empowerment and social inclusion through the
participation of both the individual with a disability and
the community in the process of rehabilitation.
CBR is often claimed to be the best approach to inclusion
and social integration, and an effective means of making
the best use of scarce resources. The WHO believes that it
promotes and protects human rights while also creating
equal opportunities and making the best use of scarce
resources.
Advocates of CBR believe that it empowers individuals to
take action to improve their own lives. Rehabilitation
takes place within the community and is fully
participatory. Community members (both with and
without disabilities) are the most important resources.
CBR depends heavily on the development of positive
attitudes and approaches among the people involved.
Active community support is vital for its success. Specialist
inputs, including appropriate medical and orthopaedic
care, remain important parts of the process, but set within
a wider context than conventional specialist care. Value is
placed on indigenous knowledge and practices, the key
being to ‘unlock’ existing expertise within communities to
help them develop their own form of CBR. This way CBR
builds on and validates existing indigenous knowledge and
information systems, while facilitating access to relevant
information and ideas from outside the community.
The concept of CBR has won widespread support, but
concerns have also been raised that negative institutional
practices and attitudes have, in some cases, simply been
relocated to the community. Also, it often takes place on a
small geographical scale, and can not provide a solution to
all problems.
In a recent paper, the Working Group on Disability and
Development of the British Organisation of NGOs for
Development (BOND) has suggested that it is essential
that people with disabilities exercise choice and control
over CBR initiatives. It advises a move to a more inclusive
approach, placing disability into a wider community
development framework. Community based
selfdetermination programmes are particularly favoured,
where people with disabilities support each other in
rehabilitation, income generation and advocacy21. The
long-term goal of CBR should be to support people with
20Beverly Ashton, A Rights-based Approach to Disability, Development and
the Intergenerational Bargain, Paper presented to the DSA Annual
Conference,
Bath, 13th Sept. 1999.
21S. Miles, Strengthening Disability and Development Work, BOND
Discussion Paper, Feb. 1999.
DFID – February 2000
9
disabilities in their efforts to take control of their own lives
and to play a decisive role in any services that are created.
22
It is estimated that the rehabilitation needs of 80% of
people with disabilities could be satisfied at community
level. The remaining 20% are likely to require referral to
some kind of specialist facility.
23 Abuses need to be
prevented, and supervisory committees need to be set up.
Standards are also required to regulate admission to, and
retention in, mental health care institutions.
22Susie Miles (SCF); Engaging with the Disability Rights Movement: the
Experience of CBR in Southern Africa, Disability and Society, Vol. 11,
No. 4,
1996, pp. 515.
23S. Miles, Strengthening Disability and Development Work, BOND
Discussion Paper, Feb. 1999.
10 DFID – February 2000
Areas for action and the role of development co-operation
Positive changes in the situation of people with disabilities
are dependent on the actions of governments, and the
empowerment of people with disabilities themselves.
A strong international commitment to uphold the rights
of people with disabilities is also an important element,
and one which can be supported through development
co-operation.
A sharper focus on disability issues, paying attention to the
rights of those directly affected and the diversity of their
experience, will help achieve greater equality of rights and
opportunities for people with disabilities and, in turn, will
help ensure that the international development targets
are achieved. The UN Standard Rules provide a
useful framework for taking this work forward. DFID
has been actively involved in disability related work for
many years, and will continue to develop its contribution
in this area.
The twin-track approach
In its pursuit of greater equality for women, DFID has
adopted a so-called ‘twin-track’ approach, combining
attempts to take account of women’s needs and rights in
the mainstream of development co-operation work, as well
as supporting specific initiatives aimed at women’s
empowerment. The analysis set out in this paper suggests
that a similar approach may be highly pertinent for work
related to disability.
The approach is summarised in Figure 3, and entails the
inclusion of an active consideration of disability issues in
the mainstream of development co-operation work, and
looking for opportunities to support more focused
activities, including direct support to organisations of
disabled people and to initiatives aimed specifically at
enhancing the empowerment of people with disabilities.
Strengthening disability work through the twin track
approach should help provide an enabling environment
for people with disabilities to achieve greater livelihood
security, greater equality, full participation in the life of
the community, and more independence and
selfdetermination.
Areas for action
There are many opportunities for action by governments
and the international community in support of people with
disabilities. Some of these are outlined below.
Policy
Good policy is an important starting point, and there is
considerable scope for dialogue, both between
governments and within the international community to
help ensure that policies are developed which seek to
uphold the rights of people with disabilities and promote
actions consistent with the UN Standard Rules.
Productive policy dialogue could be undertaken, for
example, between governments and development agencies
in the context of sector programme development, with
a view to ensuring that appropriate legal and policy
frameworks for the inclusion of persons with disabilities in
employment, social service provision and education are
developed.
Figure 3: A twin-track approach to disability and development
A twin-track approach
Addressing inequalities
between disabled and
non-disabled persons
in all strategic areas of
our work
Supporting specific
initiatives to enhance
the empowerment of
people with
disabilities
Equality of rights and opportunities for persons with disabilities
DFID – February 2000
11
The development of better data on persons with
disabilities, further broken down by gender, would be
helpful both in formulating good policy and also in
measuring progress towards the achievement of targets and
objectives. It would also help the international community
in developing a better understanding of the ways in which
the benefits of development are being shared.
Where government commitment is weak, national and
international organisations in civil society, particularly
Disabled People’s Organisations (DPOs), have an
important role to play in awareness raising and advocacy.
Economic, social and human development
Benefits are likely to be greater when services for people
with disabilities are provided within existing social,
educational, health and labour structures in society, and
where procedures are established to permit effective
participation of persons with disabilities in
decisionmaking processes.
Inclusive Education24 (IE) is an example of an inclusive
approach to development. The educational and
developmental needs of children with disabilities are more
likely to be fulfilled by their inclusion into mainstream
schooling systems (see Box 4). Inclusive education in a
developing country implies the equal right of all children
to the ‘educational package’, however basic that package
may be. A rights-based approach to education is consistent
with providing support to the inclusion rather than to the
segregation of children with a disability at school. IE is part
of a larger movement towards tackling social exclusion; it
seeks to include children on the margins of society, street
and working children, excluded minorities.
The development of national policies for education which
adopt an inclusive approach is an area where further work
is required. International development organisations have
a role to play in engaging in policy dialogue with partner
countries with a view to ensuring that appropriate legal
and policy frameworks for inclusive education are
developed.
Similar approaches can be used in relation to health. Good
practice suggests that the following principles should
be applied:
Box 4: Inclusive Education
In India, the state government of Andhra Pradesh is supporting the
inclusion of children with disabilities
and special needs in mainstream schools. The integrated education of
children with disabilities has been
implemented as a pilot project (covering 30–40 schools) under the District
Primary Education Programme
(DPEP)
25 with DFID support.
Children identified as having difficulties in the areas of gross motor, fine
motor, communication and social
development are evaluated and assessed both medically and socially, with the
help of appropriate specialists.
Following these assessments, an individual education programme is prepared
by the team for every child with a
disability. Teachers are then prepared and sensitised to the needs of the
children in question through focused
training programmes. Free aids (mobility, hearing etc.) are also provided
where required.
Through this pilot project, children with disabilities are given the
opportunity of receiving an education. They
share their classes with children who have no disabilities, and are
therefore included in mainstream school life.
Children without disabilities are themselves increasingly aware of the
capabilities and potential of their fellow
students. The pilot project will therefore have a two-fold benefit;
providing an education for children with
disabilities while challenging stigma and negative stereotypes too often
attached to these children.
Uganda has adopted a Universal Primary Education (UPE) policy which
illustrates a good way of providing
children with access to the ‘minimum educational package’. The policy,
actively supported by DFID through a
major investment programme, provides free primary education to four children
per family. It is specified in the
policy that at least two of the children should be girls (where there are
girls) and any children with a disability.
The law states that children with disabilities take priority, on the
assumption that parents are less likely to pay for
them or for girls than for boys who do not have a disability.
24Concept emerging strongly from the World Conference on Special Needs
Education, Access and Quality, held in Salamanca (Spain) in June 1994.
25It is worth noting that inclusive education is a feature of DPEP in all 15
states in which it operates.
12 DFID – February 2000
• consulting people with disabilities and their families
in health sector design, monitoring and evaluation;
• ensuring buildings used are accessible to people with
disabilities;
• taking account of the transport needs of people with
disabilities and their families to give them access to
services;
• acknowledging people with disabilities in training
materials;
• ensuring people with disabilities and their families
and project staff get access to information about
disability;
• including in programme evaluation the assessment
of impact on people with disabilities and their families
as an integral part of the general target group;
• ensure that accessible information regarding
reproductive health issues, amongst other health
issues, is available, and ensure that extra attention is
paid to women with disabilities’ needs and rights.
Employment is a key factor in the process of empowerment
and inclusion into society of people with disabilities.
The development of human resources, through skills
development and inclusive training strategies, is crucial in
facilitating the inclusion process. Ministries of
employment may need encouragement to take into
account the training needs of people with disabilities,
and to consider formulating legislation and adopting
labour standards which respect the rights of people
with disabilities to employment and income generation
schemes.
Small enterprises can provide employment and income,
and have proved particularly useful in helping people lift
themselves out of poverty. Many people with disabilities
have proven their capability to run businesses on their own
account. Much can be done to ensure that small enterprise
schemes recognise this potential and actively seek to
support its development.
Infrastructure
People with disabilities have not always had the
opportunity to participate fully and equally in the
development and management of basic infrastructure
services and shelter.
Where development organisations are involved in
infrastructure and shelter projects, local regulations on
disability should be followed as a minimum where these
exist, and otherwise, international good practice should
guide infrastructure projects. Efforts can also be made to
ensure that programmes are developed on the basis of
broad-based participation, taking particular steps to ensure
that people with disabilities and other marginalised groups
are fully included.
Conflict and humanitarian assistance
The international community responds to natural and man
made disasters with financial, material and technical
assistance. This is intended not only to save lives during
emergencies, but also to help build capacity to prevent and
avoid future disasters.
This broader-based approach requires a wider
understanding both of the contexts in which emergencies
arise, but also of the impact and consequences of different
ways of dealing with them. Wider stakeholder
participation, including a more direct involvement of
people with disabilities, is a key to developing this
understanding.
Differences in vulnerabilities of persons with disabilities
must be understood in devising responses. An example
would be the importance of considering the needs of deaf
people in accessing information. Persons with disabilities
should not be seen as victims of conflict and disasters. They
have particular capacities which can be built on in
responding to and recovering from disasters.
In addition to ensuring that the needs and rights of people
with disabilities are broadly considered, targeted
programmes may also be needed to respond to the
particular needs of people with disabilities. This can
include, for example, rehabilitation programmes for
landmine survivors.
Empowerment
A rights-based approach to disability and development
implies a right to self-representation. The rights of people
with disabilities are best promoted by people with
disabilities themselves. The growth of a democratic,
representative disability movement is one way to help
ensure that government provision is appropriate to the
needs and rights of people with disabilities. It can also help
ensure that target groups are involved in the planning,
implementation and monitoring of all disability and
development work, and to take measures to remove barriers
to participation and to combat discriminatory behaviour,
practices, policies and environments.
13
DFID – February 2000
Box 5: Empowerment and the Young India Project, Andhra Pradesh
The Young India Project (YIP)
26 provides a successful example of the kinds of empowerment
activities required for
strengthening the inclusion of people with disabilities in community life.
YIP is linked to a federation of trade
unions of agricultural and landless labourers (and their families) who
advocate for access to existent government
schemes, such as employment, income generation, housing, education and
health programmes, as well as protest
against injustices perpetrated against the rural poor.
YIP, in partnership with Action on Disability and Development (ADD), India,
has included people with disabilities
in all its work, the aim being to facilitate the access of people with
disabilities to the services, equipment and
opportunities they need to improve their own lives. Opportunities are
created for people with disabilities, through
union membership, to form supportive and campaigning self help groups and
awareness building groups.
By early 1998, YIP had unions in 209 Mandals (group of 30-50 villages) with
a total membership of more than
355,235. Work with people with disabilities makes up 25% of YIP’s work. Well
over 600 self-help groups of people
with disabilities have been formed with a combined membership in 1998 of
more than 11,000.
YIP has proved to be successful in linking disability issues into more
mainstream debates. People with disabilities
are forming their own groups as well as participating in the more general
ones. They are increasingly aware of
their rights and are able to claim and advocate for their entitlements.
Media and communications
Increasingly, media and communications are being used to
draw attention to disability issues. Television, radio, the
press, networking and lobbying can play an active role in
challenging negative stereotypes, pressing for equal rights
and raising awareness of disability.
For people with disabilities in many developing countries,
being made aware of the range of available support services
represents an important first step. In this respect, media
and communications initiatives can help people with
disabilities feel less isolated and more supported by offering
practical information and advice. Various forms of
participatory communication such as theatre, poetry and
storytelling can also play an important role in reducing the
degree to which people with disabilities are stigmatised or
discriminated against.
Disability is a rights issue and creative media initiatives
such as radio drama can be usefully employed to highlight
particularly sensitive socio-cultural issues. Fictional
portrayals allow those affected by particular
activities/attitudes and those that maintain them, to open
a critical social dialogue free from local recrimination.
Using innovative forms of communication can also help to
mainstream issues that surround disability. National
initiatives that attain a degree of mass popularity can help
promote these issues in contexts where debate did not
previously exist or where it had a low profile. This can help
to support local and national efforts to network people and
organisations that are concerned with raising awareness of
disability issues. In turn, clearly defined networks can more
successfully lobby law-making bodies to claim, protect and
maintain the rights of people with disabilities.
Gaps in knowledge
Most research into disability tends to focus predominantly
on health or social welfare aspects. There is little
coordination or integration between research on disability
and research on associated issues in gender, social
development, and human sciences. Specific attention
needs to be given to both quantitative and participatory
components in research methods to ensure that the
different dimensions of disability are appreciated.
Research on monitoring and evaluation methods and on
topics such as violence against women with disabilities,
and the sexual exploitation of children with disabilities,
are examples of specific areas requiring greater attention.
This provides opportunities for the international
community to seek a better understanding of disability.
DFID is planning to further develop knowledge of
26Partly funded by DFID through the Joint Funding Scheme (JFS), now the
Civil Society Challenge Fund, over a three-year period beginning 1994.
14 DFID – February 2000
disability and development issues, including through
applied research and its dissemination27.
Measuring progress
As with other areas of development, the availability of
adequate data for policy making, planning and measuring
progress is a challenge in work related to disability.
National governments and the international community
need to adequately resource statistical and other
monitoring systems, and make good use of available
information, to obtain more effective means of identifying
and replicating good practice.
27For example, DFID’s Knowledge and Research Health Care Technologies
Programme has been developed to establish a new inter-disciplinary
knowledge programme (Engineering, Health, Social Development) that will
support the development and application of appropriate technologies,
aiming specifically to improve the health and quality of life for poor
people in developing countries. One of the two main themes of the programme
is to minimise the detrimental effects of disability on the lives of poor
people.
DFID – February 2000
15
Annex: United Nations Standard Rules on the equalisation
of opportunities for persons with disabilities
1. Preconditions for equal participation
• Rule 1. Awareness-raising
‘States should take action to raise awareness in society about persons
with disabilities, their rights, their
needs, their potential and their contribution’
• Rule 2. Medical care
‘States should ensure the provision of effective medical care to persons
with disabilities’
• Rule 3. Rehabilitation
‘States should ensure the provision of rehabilitation services to persons
with disabilities in order for them
to reach and sustain their optimum level of independence and functioning’
• Rule 4. Support services
‘States should ensure the development and supply of support services,
including assistive devices for
persons with disabilities, to assist them to increase their level of
independence in their daily living and to
exercise their rights’
2. Target areas for equal participation
• Rule 5. Accessibility
‘States should recognise the overall importance of accessibility in the
process of the equalisation of
opportunities in all spheres of society. For persons with disabilities of
any kind, States should (a) introduce
programmes of action to make the physical environment accessible; and (b)
undertake measures to provide
access to information and communication’
• Rule 6. Education
‘States should recognise the principle of equal primary, secondary and
tertiary educational opportunities for
children, youth and adults with disabilities, in integrated settings. They
should ensure that the education of
persons with disabilities is an integral part of the educational system’
• Rule 7. Employment
‘States should recognise the principle that persons with disabilities
must be empowered to exercise their
human rights, particularly in the field of employment. In both rural and
urban areas they must have equal
opportunities for productive and gainful employment in the labour market’
• Rule 8. Income maintenance and social security
‘States are responsible for the provision of social security and income
maintenance for persons with
disabilities’
• Rule 9. Family life and personal integrity
‘States should promote the full participation of persons with
disabilities in family life. They should promote
their right to personal integrity, and ensure that laws do not discriminate
against persons with disabilities
with respect to sexual relationships, marriage and parenthood’
• Rule 10. Culture
‘States will ensure that persons with disabilities are integrated into
and can participate in cultural activities
on an equal basis’
• Rule 11. Recreation and sports
‘States will take measures to ensure that persons with disabilities have
equal opportunities for recreation
and sports’
• Rule 12. Religion
‘States will encourage measures for equal participation by persons with
disabilities in the religious life
of their communities’
16 DFID – February 2000
3. Implementation measures
• Rule 13. Information and research
‘States assume the ultimate responsibility for the collection and
dissemination of information on the living
conditions of persons with disabilities and promote comprehensive research
on all aspects, including
obstacles which affect the lives of persons with disabilities.
• Rule 14. Policy-making and planning
‘States will ensure that disability aspects are included in all relevant
policy-making and national planning’
• Rule 15. Legislation
‘States have a responsibility to create the legal bases for measures to
achieve the objectives of full
participation and equality for persons with disabilities’
• Rule 16. Economic policies
‘States have the financial responsibility for national programmes and
measures to create equal opportunities
for persons with disabilities’
• Rule 17. Co-ordination of work
‘States are responsible for the establishment and strengthening of
national co-ordinating committees,
or similar bodies, to serve as a national focal point on disability matters’
• Rule 18. Organisations of persons with disabilities
‘States should recognise the right of organisations of persons with
disabilities to represent persons with
disabilities at national, regional and local levels. States should also
recognise the advisory role of
organisations of persons with disabilities in decision-making on disability
matters’
• Rule 19. Personnel training
‘States are responsible for ensuring the adequate training of personnel,
at all levels, involved in the planning
and provision of programmes and services concerning persons with
disabilities’
• Rule 20. National monitoring and evaluation of disability programmes in
the implementation of the
Standard Rules
‘States are responsible for the continuous monitoring and evaluation of
the implementation of national
programmes and services concerning the equalisation of opportunities for
persons with disabilities.
• Rule 21. Technical and economic co-operation
‘States, both industrialised and developing, have the responsibility to
co-operate in and undertake measures
for the improvement of the living conditions of persons with disabilities in
developing countries’
• Rule 22. International co-operation
‘States will participate actively in international co-operation
concerning policies for the equalisation
of opportunities for persons with disabilities ’
DFID – February 2000
17
DFID
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