MSI Reproductive Choices: Submission to the International Development Committee’s Inquiry on FCDO and Disability-Inclusive Development

September 2023

Background

MSI Reproductive Choices (MSI) is one of the world’s largest providers of sexual and reproductive health services, and an advocate for reproductive choice. We work in 37 countries as a key partner to ministries of health, private providers, and civil society organisations. Last year we reached 21.1 million clients with sexual and reproductive healthcare.

MSI is proud to be a key partner to the Foreign Commonwealth and Development Office (FCDO) in implementing UK government commitments to sexual and reproductive health and rights (SRHR), disability, and gender equality, consistently delivering ground-breaking, rights-based programmes at scale, whilst providing results and value for money to the UK taxpayer.  

MSI and our consortium partners currently receive UK Aid to implement the UK government’s flagship SRHR Women’s Integrated Sexual Health (WISH) Lot 1 Programme as well as implementing multi-year bilateral programmes in Pakistan (Delivering Accelerated Family Planning in Pakistan), Sierra Leone (Saving Lives II), Tanzania (Scaling up Family Planning), Uganda (Reducing High Fertility Rates and Improving SRH Outcomes) and Afghanistan (Supporting Afghanistan’s Basic Services).

1. The adequacy of FCDO’s new disability and inclusion rights strategy as a framework for approaching disability-inclusive development.

MSI warmly welcomes FCDO’s Disability and Inclusion Rights Strategy and the inclusive, and comprehensive vision it sets out. The principles of freedom, individual agency, choice, and dignity resonate with our own approach, and set out an ambitious and empowering framework not just for HMG but for other donors and the wider international community with which they work. To ensure effective implementation we recommend:

• Increased and clearer financial commitment to the Strategy’s delivery plan and earmarking of disability related funding across relevant programmes.
• More rigorous and regular reporting and accountability requirements on the 1,000 commitments made at the Global Disability Summit.
• More intensive socialisation to ensure the Strategy is better known, understood, and valued across Whitehall, and to ensure greater domestic and international policy coherence.
• Roll out and promotion of the Strategy within the multilateral institutions which the FCDO supports, to both ensure institutions are aware of the UK’s commitments and that funding is aligned with the Strategy’s principles and approach.

Since 2018, MSI Reproductive Choices has led one of two consortia under the Women’s Integrated Sexual Health (WISH) programme, FCDO’s flagship investment to scale up support to integrated SRHR services across Africa and Asia. A core objective of the programme is to provide high quality services to those traditionally marginalised and excluded from access, including people with disabilities.

The FCDO’s explicit inclusion of disability within the Terms of Reference for the WISH Programme led to the inclusion of a disability partner within the consortia, firstly Leonard Cheshire and then, since April 2023, Sightsavers. Partnering with these agencies has had a transformative impact on disability inclusion not just within the WISH programme but across MSI’s global operations, services, advocacy, and communications.

For example, this dedicated funding and partnerships have been the catalyst for numerous positive outcomes, including:

• Before WISH, an estimated 1% of our clients in the West and Central Africa region were people with disabilities, in 2020 nearly one in ten of our clients (9%) attending WISH services provided by MSI and partners was a person with a disability.  
• We now include the Washington Group Short Set on Functioning (WG-SS) in our global annual client exit interview survey and encourage partners to do the same where appropriate.
• Principles of disability inclusion are now deemed essential for all our staff and providers at all levels of our organisation. MSI worked with Leonard Cheshire to develop a wealth of materials and training resources that are available to WISH partners and the wider sector. They include Accessible Client-Facing Communications Guidelines; a Disability Audit Tool; a Guide on Conducting Community Engagement Workshops with Clients with Disabilities; a Disability Inclusion Values Clarification Attitudes Transition Toolkit developed with Ipas; a Report on Seeking Informed Consent and Safeguarding Clients with Intellectual and Sensory Disabilities; and an E-learning course of 7 modules to develop knowledge, attitudes and practices which are more inclusive of people with disabilities that are available on MSI’s global eLearning platform.
• Leonard Cheshire supported us to build capacity and generate learnings. For example, in Sierra Leone we worked with Leonard Cheshire, ThinkPlace and the Sierra Leone Union on Disability Issues through a human-centred design process, to listen to, and learn from women living with disabilities about their experiences in accessing services; to identify opportunities to address the barriers they face; and to co-design prototype solutions. Building the capacity and confidence of MSI staff was identified as an opportunity and the resultant Inclusive Services Guide is a booklet for providers with easy-to-implement guidance on how to better prepare for, and tailor services for clients with different disabilities.
• More proactive engagement with ‘Organisations of Persons with Disabilities’ to involve persons with disabilities more systematically in design and decision-making processes for SRHR service delivery and policies, for example, consulting on where best to position outreach teams to provide convenient services and ensuring that new SRHR policies are informed by disability and inclusion.
• Disability inclusion has been adopted not only by MSI but all WISH partners who proactively develop inclusive programming and seek Leonard Cheshire and Sightsavers’ technical support, leading to an equally significant shift in their approach to SRHR.

2. The adequacy of FCDO’s spending on disability-inclusive programmes and the impact of cuts to ODA programmes on people with disabilities

The impact of the cuts to ODA on the WISH programme has been well documented in previous submissions and taking the MSI component of WISH as an example the programme budget from 2019/20 to 2023/24 was cut by 79%. These cuts deeply undermined the ability of this ground-breaking programme to achieve its already ambitious transformational and sustainable objectives, and what has been particularly challenging is not just the reduction in budgets, but the numerous rounds of cuts and amendments often at the eleventh hour.

However, the prioritisation of disability within WISH by both the FCDO and implementing partners was crucial to safeguarding this programme against the recent background of cuts and uncertainty, and to ensuring that cuts were applied proportionally across programmes.

Explicitly safeguarding disability funding when programmes are cut: The historical under prioritisation of people with disabilities has demonstrated that unless specific steps are taken around disability inclusion people with disabilities will not benefit from development programmes. Disability inclusive programmes are often more expensive and recent cuts to the aid budget have forced implementers to make difficult decisions. Whilst we managed to replan support for disability focussed activities, within the WISH cost extension, this was our decision (with FCDO’s support). The Equalities Impact Assessments have highlighted that the cuts are likely to affect the most marginalised, including people with disabilities. Given this we would suggest that the FCDO be more explicit about safeguarding disability funding in any future cuts.

Scaling up technical expertise on disability: In some cases, additional technical support on disability issues would have been valuable and this is an area where the FCDO should consider additional investment, particularly in relation to more sophisticated and nuanced monitoring and evaluation. For example, support in the development of disability metrics and indicators would have been helpful. We currently use ‘% of clients reporting living with a disability’ collected through an annual survey but this doesn’t capture quality, improvement over time or inclusivity of services, and the sample size is often too small to be meaningful. Although widely used, these questions only identify people with significant disabilities, and they don’t address psychosocial functioning or mental health. A greater commitment to disability and inclusion needs to come with deeper thought about how we monitor and evaluate programming and using KPIs for disability would also enhance investment on disability inclusion.

Increased support for SRHR: Whilst SRHR is referred to in the Strategy we would like to see additional support for SRHR disability related programming, policy and advocacy initiatives. This is because SRHR of people with disabilities have been widely and deeply neglected.[1] These issues have not been adequately mainstreamed or addressed by the disability community, by health providers or by those working on SRHR. As a result, millions of people with disabilities still lack access to quality reproductive health services, information and choice which exacerbates the poverty, inequity, and stigma which many people with disabilities experience. The WHO reports that people with disabilities are more than twice as likely to report finding healthcare provider skills inadequate to meet their needs, four times more likely to report being treated badly and nearly three times more likely to report being denied care.[2]

Throughout history people with disabilities have been prevented from fulfilling their SRHR. They have often been denied the right to establish relationships; to decide whether, when, and with whom to have a family; or a choice of contraceptive method. Persons with disabilities are up to three times more likely than non-disabled persons to be victims of sexual abuse and rape.[3] They are more likely to become infected with HIV and other sexually transmitted infections, due to a lack of access to prevention information and services, and higher rates of sexual and gender-based violence. In conflict and crisis settings these risks are multiplied. The assumption that young people with disabilities will not be sexually active can result in little or no sex education. As a result, young people with disabilities often lack the information and services they need to control their reproductive health, and to make informed choices about relationships, sex and contraceptives.

We would therefore encourage future health programmes to:

• Facilitate new partnerships to encourage collaboration between organisations of persons with disabilities, agencies that specialise in disability issues and specialist SRHR service delivery organisations - to develop alliances that can deliver services at scale and mainstream services for people with disabilities into existing programmes.
• Support inclusive services to ensure that people with disabilities, particularly those from poorer or marginalised communities, can get information about, and access to, comprehensive, affordable and non-discriminatory SRHR services - and to ensure that existing services do not unintentionally discriminate.
• Strengthen integration: Identify solutions that will improve access - looking beyond ‘physical access’ to address barriers such as cost, the limited availability of services, and provider discrimination or inadequate skills. For example, communicating health information in accessible formats and integrating disability education into training for all health workers.
• Give particular attention to unsafe abortion and obstetric fistula[4] that are at risk of falling between programmes that focus on health, disability or women’s right.

Persons with disabilities have the same SRH needs as other people. Yet they often face barriers to information and services. The ignorance and attitudes of society and individuals, including health-care providers, raise most of these barriers - not the disabilities themselves. In fact, existing services usually can be adapted easily to accommodate persons with disabilities. Increasing awareness is the first and biggest step. Beyond that, much can be accomplished through resourcefulness and involving persons with disabilities in programme design and monitoring.                                           WHO/UNFPA Guidance Note, 2009