Sightsavers Submission to the International Development Committee on ‘Sexual and reproductive health of women and girls in lower-income countries: is the FCDO doing enough post-pandemic?

April 2023

About Sightsavers

Sightsavers is an international development organisation which works with partners to eliminate avoidable blindness and promote equality of opportunity for people with disabilities in over thirty low- and middle-income countries. Our programmes also include working to ensure quality inclusive education, strengthen health systems and eliminate neglected tropical diseases (NTDs).

We welcome the opportunity to contribute to the International Development Committee’s inquiry on ‘Sexual and reproductive health of women and girls in lower-income countries: is FCDO doing enough post-pandemic?’ Our submission focuses on women and girls with disabilities and how the UK’s development programme should protect and promote their sexual and reproductive health rights (SRHR).

Summary

Women and girls with disabilities face multiple and intersecting barrier in claiming their full range of sexual and reproductive rights (SRHR). This includes inaccessible services, goods, and information on SRHR, as well as stigma and discrimination from communities, health workers and policy makers. Despite this, analysis of available OECD DAC data suggests that only 25% of the UK’s SRHR programming is disability inclusive[1].

It is critical that the UK’s and FCDO’s approach to SRHR is fully disability inclusive to properly respond to the needs of all communities and that this this is not compromised by pressures on the Official Development Assistance Budget. This is crucial to achieve the ambition set out in FCDO’s Disability Inclusion and Rights Strategy.

To achieve this the FCDO should take further steps to mainstream disability inclusion across its SRHR funding and make specific and concrete targets. In particular, the FCDO should aim to set a target percentage of SRHR programmes to be marked as disability inclusive using the DAC marker which should double the existing baseline. FCDO should also incorporate the SRHR of all people with disabilities as a core component of SRHR funding streams, emphasising their bodily autonomy and decision-making capacity and the multiple and intersectional discrimination faced in claiming their rights. Additionally, FCDO’s SRHR programmes should include a dedicated budget, baselines, targets, and key performance indicators focusing on the inclusion of people with disabilities, and particularly women and girls ensuring the equitable allocation of budget for the inclusion of people with disabilities. It is also essential that disability is mainstreamed across all areas of the delivery plan to effectively implement FCDO’s new Women and Girls Strategy.

SRHR for people with disabilities

An estimated 16% of the global population and 18% of women are women with disabilities.[2] Women with disabilities continue to face multiple barriers in claiming their full range of sexual and reproductive rights. Women and girls with disabilities are denied SRHR information, denied rights to establish relationships and to decide whether, when and with whom to form a family. They experience forced sterilisation and contraception, female genital mutilation, coerced abortion and, on the other hand, lack of access to contraceptive information and services, maternal health care and fertility treatments.

SRHR information and services are often physically inaccessible and communication of SRHR messaging tends to be inappropriate and inaccessible for people with visual and hearing impairments and people with intellectual disabilities[3]. This may lead to women and girls being unable to access family planning methods, agreeing to the uptake of certain methods without uncoerced and fully informed consent, as well as barriers in having a healthy pregnancy and giving birth safely[4].  

People with disabilities face stigma, negative attitudes and discrimination from communities and health workers leading them to be denied access to information and services[5]. This is linked to the societal prejudice towards people with disabilities, including myths that are not sexually active or cannot or should not become parents.[6]

Women and girls with disabilities are often discriminated against from the onset of pregnancy right through to motherhood, linked to prevailing myths and false assumptions, such as that people with disabilities would not be able to take good enough care of their children[7]

People with disabilities are often treated as either asexual or hypersexual and therefore are at increased risk of rape, forced marriages, sexual exploitation, forced sterilisation and unwanted or forced pregnancies.  Women with disabilities are also reportedly at two to four times higher risk of Intimate Partner Violence (IPV) than women without disabilities and are likely to feel more isolated and less able to report abuse if they rely on the abuser for their care in addition to being less likely to be believed if they do so.[8]

Adolescent girls and young women with disabilities face particular challenges in accessing their sexual and reproductive health and rights. This multiple and intersectional discrimination due to gender, youth, race and disability results in adolescent girls and young women with disabilities being excluded when trying to access their SRHR[9]. There has been a prioritisation in the development over the past few decades on ‘controlling’ adolescent girls’ sexuality, often resulting in a focus on reducing fertility rates rather than on championing adolescent girls’ rights and bodily autonomy. For young women with disabilities this intersects with the stigma they experience on the basis of disability.

LGBTQI+ people with disabilities often face multiple barriers in accessing SRHR services because of a lack of inclusive SRHR information and services and due to discrimination by healthcare providers alongside legislation which criminalises same-sex relationships.8

Barriers to accessing SRHR information, goods, services and exercising bodily autonomy were exacerbated for people with disabilities during the COVID-19 pandemic[10]. For instance, some women and girls with disabilities who require sign language interpreters or other assistants to access SRH services were no longer allowed to bring individuals with them due to social distancing rules.

Is the FCDO’s approach to sexual and reproductive health programming in lower-income countries sufficiently responsive to the needs of communities in lower-income countries, including in its new Sexual and Reproductive Health and Rights programme?

As set out above, it is critical that the UK’s approach to SRHR is disability inclusive, as only then can it respond to the needs of communities, particularly those who are least likely to be able to realise their sexual and reproductive health rights.

As raised by the Committee previously there is challenges in fully assessing the UK’s ODA currently due to a lack of publication of documents and statistics in a fully transparent format in recent years. However, from what data exists we have reason to believe that there is some positive practice in relation to disability inclusive SRHR programming, outlined below, but that there remain gaps. Analysis of available OECD DAC data suggests that only 25% of the UK’s SRHR programming is disability inclusive[11].

Although up to date information is not available on all programmes there is some promising examples where disability well included in the Business Cases for SRHR programmes, which is positive. The business cases for the Partnership in Maternal Newborn and Child Health (PMNCH) and the FP2030, for example, both reference disability inclusion and the FCDO’s engagement in disability inclusive SRHR. It is concerning however, that while a commitment to mainstreaming disability inclusion exists in the Business Case for the PMNCH funding, there is no indicators in the logframe. We know that this can impact on the extent to which disability inclusion is realised in practice. There is also no information about whether cuts to budgets have impacted on disability inclusion within these programmes.

Sightsavers is involved in several FCDO funded SRHR programmes which we have set out more details of below and from which we have drawn several recommendations.

Inclusive Family Planning (IFPLAN)

As part of the UK’s flagship Disability Inclusive Development (DID) programme there is a specific programme on SRHR, the IFPLAN project in Northern Nigeria[12].

The project aims to reach approximately four million people – including 72,000 people with disabilities directly, and 576,000 indirectly through targeted social and behaviour change (SBC) messages – and to strengthen health systems and services in Kaduna, mainstreaming disability inclusion throughout.

This project is implementing awareness raising and SBC approaches. For example, a radio drama focusing on access to family planning and SRHR for people with disabilities will be broadcast. Meanwhile, accessible, and inclusive community level SBC approaches and materials are being finalised and will be used to train and influence community members, traditional and religious leaders, people with disabilities and their families, as well as 1,500 health workers to promote more equitable access to family planning.

To ensure accessibility of services accessibility audits have now been completed for 24 health facilities, along with disability inclusion score card assessments of targeted service providers – and we will be working with local authorities to incorporate accessibility features in the refurbishment process.

Representatives of Organisations of Persons with Disabilities (OPDs) have been selected to lead the project Steering Committee which oversees the governance of the project. Having received training in advocacy, health financing and inclusive SRHR, OPDs have developed an advocacy plan and will lead key activities to promote health equity for people with disabilities within the health sector. This is critical to ensure the participation of people with disabilities in decision-making and development of all policies and legislation focused on sexual and reproductive health and rights. 

The IPLAN project has the potential to demonstrate approaches that work on disability inclusion. The FCDO should ensure that they use these lessons to inform future programme design. This will be most effective if these lessons are used to inform larger programmes.

There is an opportunity to do so in Nigeria, thanks to links between IFPLAN and the FCDO SRHR programme Lafiya. Due to severe budget cuts, disability inclusion was not built into the Lafiya programme from the beginning, but there has been some progress recently, thanks to the collaboration with IFPLAN. One of Sightsavers disability inclusion technical advisors is now partially seconded to Lafiya, we have conducted a disability inclusion training for Lafiya staff, and we are having ongoing bilateral conversations to explore entry points for disability mainstreaming. In future, disability inclusion should be built in from the start to ensure that it is effectively mainstreamed. However, there will also be lessons for the FCDO from the collaboration between the two programmes which they should look to build on.

Women’s Integrated Sexual Health (WISH) Programme

The WISH programme is the FCDO’s flagship SRHR programme[13] and includes a crucial component to improving access to SRHR for people with disabilities.

The WISH programme has partnered with OPDs and trained people with disabilities to become community-based mobilisers to raise awareness of the rights of people with disabilities to access SRHR services. This has been essential to provide contraceptive methods and information on family planning services to other people with disabilities within communities – as well as the production of accessible and inclusive information and communication materials to be used during counselling sessions.

Service providers, government officials, and other stakeholders have also been trained on the rights of people with disabilities and the importance in increasing access to SRHR services for all. Consortium partners have also been working with government departments at different levels to review family planning and SRHR legislation and mainstream disability inclusion within these policies and frameworks.

However, throughout the duration of WISH, there have been multiple budget cuts which have affected the consortiums’ ability to deliver effective and responsive SRHR programme interventions. In the costed extension (April 2023 – March 2024), the budget has been reduced to around 50% of the original budget. This has resulted in scaling back Sightsavers inputs – alongside all consortium partners - and our ability to support country programmes and consortium partners in ensuring SRHR services are accessible.

While the consortium leads have maintained the same proportional focus on disability this has not been requested or advised by the FCDO. We are aware of other programmes where this lack of focus by the FCDO has led to disproportionate cuts to funding for disability inclusion. Given the FCDO’s focus on SRHR in the new strategy it is particularly concerning that such significant cuts were made to WISH. It is also not possible to see whether an equalities impact assessment was done and acted on in making this decision. 

Does the FCDO’s new global Women and Girls strategy sufficiently address sexual and reproductive health?

FCDO’s new Women and Girls strategy is a positive step forward to ensure that the UK government furthers its global leadership on gender equality[14]. We welcome the commitment that 80% of FCDO’s aid programmes will have a focus on gender equality by 2030.

At the Global Disability Summit (GDS) in 2022[15], the UK Government committed that the ‘2022 Women and Girls Strategy will ensure that women and girls with disabilities are meaningfully embedded across key priorities and mutually reinforce the 2022 FCDO Disability Inclusion Strategy’.

However, the Women and Girls Strategy fails to mention the Disability Inclusion and Rights Strategy[16] and misses out many of the key commitments that were made on SRHR. For example, the Disability Inclusion and Rights Strategy commits to ‘ensure women and girls with disabilities in all their diversity can access their full SRHR services through influencing global advocacy programmes such as the Partnership for Maternal, New-born and Child Health’. It also commits the FCDO to ‘strengthen SEAH prevention and response in all programmes and across the wider aid sector, paying specific attention to safeguarding people with disabilities’. It is essential that these commitments are addressed in the implementation of the Women and Girls strategy.

Despite the GDS commitment to embed women and girls with disabilities across the key priority areas of the strategy, the specific barriers they face are not recognised or addressed across many of the priority areas, particularly on SRHR. This overlooks the fact that women and girls with disabilities face intersectional and multiple barriers in claiming their full range of SRHR.

The strategy highlights that the UK hosted the international Preventing Sexual Violence in Conflict Initiative (PSVI) Conference in London and launched a new Political Declaration. Although this is a positive step, the Political Declaration and its commitments to action do not address the specific barriers and needs of women and girls with disabilities. Additionally, disability inclusion is not included or mainstreamed in the UK’s new PSVI Strategy. It is crucial that the International Alliance on PSVI has meaningful representation of women and girls with disabilities and mainstreams disability in its work to coordinate international action to prevent and respond to conflict-related sexual violence.

Delivery plan and accountability

The development of the delivery plan is an opportunity to address the lack of inclusion of disability across the strategy. It is essential that disability is mainstreamed across the milestones and tracking of progress and includes specific indicators and targets on disability inclusion for each.

For example, there should be a specific target to double the percentage of SRHR programmes marked as disability inclusive using the OECD DAC marker.

The delivery plan should also align with the GDS commitment to ‘embed results tracking disaggregated by disability and the use of the Washington Group of Questions, across all new activities including health, social protection, and education’.

The new biennial public report on progress against the strategy should assess the reach and impact on women and girls with disabilities, detail lessons on disability inclusion and expand the evidence base on the intersection between gender and disability in SRHR.

The External Gender Challenge Board of experts is a good initiative to hold FCDO accountable for the delivery of this strategy, and we are pleased that this will include representation from women and girls from communities who have been marginalised. It is essential that this has meaningful representation of women and girls with disabilities and their representative organisations to provide advice and expertise on the implementation of the strategy.

Recommendations

Within this section we have predominantly focused on answering the question in the ToR of how the FCDO can target the use of funding for sexual and reproductive health programmes more effectively as well as drawing in recommendations from the questions addressed above.

Recommendations on strategy and accountability:

1. FCDO should  set a target percentage of SRHR programmes to be marked as disability inclusive[17] using the OECD DAC disability marker. We suggest that this should be at least double the existing baseline.
2. All FCDO’s SRHR programmes should include a dedicated budget, baselines, targets, and key performance indicators focusing on the inclusion of people with disabilities, and particularly women and girls ensuring the equitable allocation of budget for the inclusion of people with disabilities. These should be meaningful targets that do not create perverse incentives, for example they should not be focused on the number of women with disabilities accessing contraception as this can privilege approaches that do not focus on autonomy[18].
3. FCDO’s assessment of the effectiveness of current UK-funded programmes on the provision of sexual and reproductive health services should pay particular attention to the extent to which it includes people with disabilities. 
4. FCDO should require partners to incorporate the SRHR of all people with disabilities as a core component of SRHR funding streams, emphasising their bodily autonomy and decision-making capacity and the multiple and intersectional discrimination faced in claiming their rights.
5. The FCDO should publish a new Inclusive Data Charter Action Plan and this should contain specific commitments on improving data on SRHR and disability, in way which does not risk further rights violations for people with disabilities.

Recommendations on targeting of funding:

1. The FCDO should target funding to support national governments to pass and enforce legislation and policy which specifically recognises the SRHR of all people with disabilities and prohibits harmful practices, including forced sterilisation and contraception, coerced abortion, and female genital mutilation.12 

2. FCDO should target funding and support governments to ensure the development of progressive and inclusive systems of health financing that address the many intersecting financial barriers experienced by people with disabilities in accessing health services, including SRH services.

3. FCDO should allocate funding to support governments to ensure that sexual and reproductive health information is accessible and inclusive, and that all people with disabilities are informed of their rights[19].

4. Specific funding should be allocated to support national governments to collect, analyse and use disaggregate disability data around provision of sexual and reproductive health information and services, integrating internationally comparable methodologies as part of population-based surveys and routine data collection procedures, to inform improvements in policy and services. FCDO should also champion the use of the Inclusive Data Charter and encourage partners to do the same to ensure that data is disaggregated by disability, age, and sex through more systematic application of the Washington Group Question Sets.

5. Funding should be targeted to ensure the provision of comprehensive sexuality education to children and young people with disabilities in an accessible and age-appropriate format to support them in their sexual development and contribute to their well-being and health.

6. In the design of programmes specific funding should be included to ensure the meaningful participation and consultation of people with disabilities and their representative organisations in decision-making and development of all policies and legislation focused on SRHR.

For more information, please contact Hannah Dawson, Social Inclusion Policy Officer (hdawson@sightavers.org) or Ross Gilligan, Parliamentary Adviser (rgilligan@sightsavers.org)

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