International Development Committee inquiry

FCDO's approach to sexual and reproductive health

Written evidence submitted by CBM UK

April 2023

CBM UK works in the world’s poorest communities to fight poverty and exclusion across lower income countries to prevent blindness, improve health, build inclusive communities and transform the lives of people with disabilities. We believe that all people are equal, that our world needs everyone and that people with disabilities should participate in all spheres of society on an equal basis, without discrimination, alongside their non-disabled peers to build a world in which all people are included, valued and respected.

It is important to specifically recognise women and girls with disabilities within sexual and reproductive health rights (SRHR) programming in communities of lower-income countries.

Women with disabilities face particular challenges in accessing SRHR care as initiatives, programmes and facilities are often inaccessible to them, physically, environmentally and socially.

Globally, an estimated 19 per cent of women have a disability, (compared to 12 per cent of men)[i]. In every country with available data, more women than men are recorded to be living with a disability[ii]. This background is compounded by their experience of poverty in that 22.1 per cent of women in lower income countries have a disability, compared to 14.4 per cent in higher income countries[iii]. Women living in poverty are also more likely to acquire disabilities and, every minute; more than 30 women are seriously injured or acquire a disability while labouring during childbirth[iv]. In addition, globally, women with disabilities are two to three times more likely to experience physical or sexual violence than women without disabilities[v].

Women with disabilities in low-income countries continue to experience lower rates of access to education, employment and health services than either men with disabilities, or women without disabilities. The FCDOs own Women and Girls strategy acknowledges that “More than nine in ten of all maternal deaths occur in the world’s poorest countries. Multiple, overlapping forms of discrimination increase the levels of extreme disadvantage and vulnerability.” As a result, whilst disability rights must consider the impact of gender, any explorations of women’s and girl’s rights must consciously consider the prevalence and lived experience of disability. 

The barriers faced by women and girls with disabilities to accessing SRHR.

In most low-income countries, the major reasons for women not seeking SRHR healthcare within their communities are financial constraints, lack of support from husbands, distance to travel to health facilities, and the fact that local health facilities cannot meet demand, due to a lack of health workers, equipment and electricity supply[vi]. Women and girls with disabilities face additional barriers, and are often overlooked in SRHR services, as they can be shunned and discriminated against by their communities, unable to continue education or find employment, and are therefore often reliant on family members for survival, and can develop other disabilities including mental health and psychosocial disabilities. Alongside these individual, familial and community barriers are those faced by women and girls within health care systems including stigma from the SRHR staff and physical access barriers to SRHR services. All contribute to the fact that women and girls with disabilities are too often left behind in SRHR responses.

What is needed to break down the barriers to accessing SRHR through FCDO funded programmes?

It is crucial that specific FCDO programming provides technical support and development of health facilities to improve accessibility by ensuring that all health facilities are physically accessible. In addition there needs to be specific training given to health workers on care for women and girls with disabilities and inclusive-SRH services, and for other accessibility needs to be met, for example sign language interpretation to be available to improve communication with women and girls who are deaf. Specific interventions, such as the distribution of assistive devices, including wheelchairs, tricycles and crutches, are also required to enable engagement.

Programming must have specific funds allocated to improving national regional and community understanding of the barriers women and girls, including those with disabilities, face in accessing SRHR services and must have effective vehicles for advocacy with government to overcome the issues. Programming must draw on women and girls own experiences to help other women and girls challenge stigma and enable them to access the full range of support needed. Funding must also help train people from community and religious groups as well as schoolteachers to be community champions and advocating for the needs of women and girls with disabilities to be included into state and local government SRH plans and programmes.

How can these barriers to SHR be overcome?

CBM has experience on how improving accessibility for women with disabilities within SRHR can have a huge and lasting impact on them, their families and communities. We have seen, for example, in our collaboration with Survive Fistula Healthcare Foundation and ECWA Vesico Vaginal Fistula Centre in Central and North-Eastern Nigeria, locally based programmes which have brought about sustainable and transformational change. We saw a significant improvement to access to quality maternal and new-born health services as well as preventing and treating obstetric fistula, a debilitating condition which around 13,000 women in Nigeria develop every year and currently affects an estimated 150,000 women and girls in Nigeria[vii].

The stigma around obstetric fistula means the real figures may be much higher as women and girls often do not seek help, as many feel ashamed and isolate themselves from others, leaving them prone to infection, not realising that fistula is a medical condition that can be treated. Through our partnerships, women with lived experience of fistula are trained to be community champions, to raise awareness – including the treatment available – and to tackle stigma and discrimination in their communities. They do this alongside trained health workers in antenatal, emergency obstetric and new-born care to improve maternal healthcare in Nigeria and end the needless suffering of thousands of women living with obstetric fistula.

Due to the stigma they face women with disabilities are often only discovered and referred for treatment through targeted community outreaches. The outreaches raise awareness of SRHR and enable women to make informed decisions about their health, help to prevent conditions like fistula, and provide support for people with disabilities during pregnancy and childbirth.

Working in Partnership with Organisations of Persons with Disabilities 

A crucial aspect to the success of these SRHR programmes has been working in partnership with local Women’s groups and Organisations of Persons with Disabilities (OPDs) to ensure that women and girls – including those with disabilities – are educated about maternal and child healthcare. This involves OPDs and their members training members of community and religious groups, and school teachers to become women’s health champions in their communities, and providing the capacity to raise awareness about the need for SRH care to everyone. OPDs play a critical role in supporting women with disabilities who are experiencing sexual violence, amplifying the voices and experiences of women and girls with disabilities who have often been excluded from mainstream services to influence service providers and governments to better include all women and girls, of all abilities.  With this is mind CBM UK welcomes the new FCDO International Women and Girls Strategy commitment to “Support grassroots Womens Rights Organisations and movements to operate and grow in effectiveness, including those focused on disabilities and minority rights.”

The underlying budgetary issue

So often, the inclusion of women and girls with disabilities within SRHR programmes and budgeting is seen as an additional extra, a luxury even, rather than being a core and prioritised component. It is easier to overlook or regard the accessibility needs as being “too expensive” so that people with disabilities are not been prioritised, despite being overrepresented amongst those living in poverty and experiencing significant levels of discrimination. Unfortunately, we know that when budgets are constrained, provisions which support people with disabilities are often the first to be cut[viii]. The UN Convention of the Rights of Persons with Disabilities, to which the UK is a signatory, requires equality of access. Article 25 states that person with disabilities must be provided with “the same range, quality and standard of free or affordable health care and programmes as provided to other persons, including in the area of sexual and reproductive health and population-based public health programmes”.  It is important therefore that constraints on the UK ODA budget do not undermine the provision of appropriate funding and equality of access to SRHR programmes to deliver the commitments under both the DIRS in alignment with the WGS.

The Women and Girls Strategy (WGS) linked to the Disability Inclusion and Rights Strategy (DIRS)

Women and girls, including those with disabilities, must be intentionally engaged as active agents of change, able to advocate for their own priorities, and not treated as passive beneficiaries, so as to be enabled to positively seek to transform attitudes by reducing discrimination and see better sexual and reproductive health benefits and improvements for all. CBM UK therefore welcomes the acknowledgement within the newly launched FCDO International Women and Girls Strategy (WGS) that “Women with access to sexual and reproductive health services and rights are more likely to complete their education, take up better opportunities and contribute to the growth and prosperity of their families and countries.” It is crucial that such commitments to advancing gender equality are made and advanced by the UK Government at an important moment in time when the rights and freedoms of women and girls are being eroded in many countries around the world.

However the FCDO’s new WGS does not sufficiently address sexual and reproductive health in responding to or acknowledging the needs of women and girls with disabilities, especially within lower-income countries. The WGS fails to specifically mention, when referencing SRHR, women and girls with disabilities, or include any references to and align itself with the FCDO Disability Inclusion and Rights Strategy. This, alongside the ongoing nature of ODA budget cuts, causes concern that marginalised groups, including women and girls with disabilities could be overlooked in SRHR programming and funding allocations.

Consequently, it is imperative that the FCDO’s approach to SRHR programming, because of the known experiences of lack of access to SRHR and the stigma experienced by women with disabilities who try to access it, alongside the increased sexual violence experienced by women with disabilities, requires specific targets, focus and funding for women and girls with disabilities.

The FCDO DIRS has a stated ambition:

“For people with disabilities everywhere to access and use affordable, accessible, and quality health services throughout their life so they can make and act on informed decisions about their own health. This includes preventive, promotive, curative, rehabilitative and palliative health services, as well as sexual and reproductive health and rights services and assistive technology provision.”

Again CBM UK welcomes this ambition alongside further commitments to:

“remove barriers to equal, affordable, accessible and quality health services and ensure people with disabilities have access to gender-sensitive health services including SRHR”

and “also strive to ensure women and girls with disabilities in all their diversity can access their full Sexual and Reproductive Health and Rights services through influencing global advocacy programmes such as the Partnership for Maternal, New-born and Child Health Surgeries and support”.

These are all important and much needed commitments. What is now needed is the alignment and translation of these into concrete actions in the delivery plans of both the WGS and DIRS with specific aims and targets for performance and funding, and clear indicators and specific timelines on all SRHR programmes that provide clarity as to how these commitments will be implemented and worked through, and so enable a strong qualitative accountability mechanism. Without these the very women and girls that are said to be being supported and empowered will have no way of knowing what is hoped to be achieved will be. 

Recommendations

CBM UK believes that the UK’s international aid budget is most effective and impactful when underpinned by a rights based approach committed to active engagement with those more marginalised, including persons with disabilities. This is achieved through authentic partnerships between all levels of society, government, business and non-governmental organisations, and will involve providing funding for good quality services which are accessible to all.

We recommend for the FCDO's approach to sexual and reproductive health that:

1. Any new delivery plan for SRHR within the Women and Girls Strategy and any FCDO SRHR programmes must have ambitious targets and funding allocations that are inclusive of and aligned to the Disability Inclusion and Rights Strategy and must be generated and developed in partnership with women and girls with disabilities and their representative organisations, ensuring they are fully represented and engaged.
2. Disability rights and inclusion are elevated as a core component of the whole FCDO SRHR programme and response as a cross-cutting issue acknowledging its relevance to every aspect of SRHR.
3. All SRHR programming and funding integrates a full disability analysis, including disaggregated data, identification of barriers for women and girls with disabilities, and strategies for inclusion of women and girls with disabilities.  
4. All SRHR initiatives across the programme include women and girls with disabilities at the design phase and throughout delivery and evaluation.

CBM UK, Munro House, 20 Mercers Row, Cambridge CB5 8HY

Contact Mark Barrell, Head of Advocacy: markb@cbmuk.org.uk