WRITTEN EVIDENCE SUBMITTED BY

HUMANITY & INCLUSION

Humanity & Inclusion (HI) is an independent aid organization working in situations of poverty and exclusion, conflict and disaster. HI works alongside disabled and vulnerable people in over 55 countries worldwide.

As a humanitarian and development actor, HI is particularly worried about the impact of this crisis on developing countries, especially regarding the humanitarian impacts in emergency settings and the significant effects on the most vulnerable population, including persons with disabilities, people with chronic disease and older people. The unprecedented scope and gravity of this crisis calls for international solidarity, and a coordinated and ambitious response at global level. To this end, HI advocates for scaling up and adapting the response, recognizing the role of NGOs as essential front-line actors.

I-                               Executive summary

• 94% of the 55 countries in which HI is working are already affected by the COVID-19 outbreak (18 are in total lockdown and 28 in partial lockdown).

• COVID-19 will significantly impact already-fragile health systems. In Yemen only 51% of health centres are fully functional, at end 2019 no district in North-East Syria met the emergency threshold of at least 10 beds per 10,000 population, and in Mali there is only one ventilator for the whole country.

• The COVID-19 pandemic heightens the risk of exposure, complications and mortality rates for specific vulnerable, marginalized and most at risk groups, including older persons, persons with disabilities, persons living with a chronic disease, migrants, refugees, internally displaced persons, mine/ERW survivors etc

• Many persons with disabilities are either older or have underlying health conditions that increase the risk of infection and serious complications from COVID-19. In contexts of conflict and acute humanitarian crisis, where prevalence of disability is higher (27% in Syria, versus 15% global average) this may mean a disproportionate impact of COVID-19.

• Persons with disabilities are already feeling the impact of COVID-19. In Nepal, in a survey of almost 700 people with disabilities, 29% reported mental health impacts such as increased anxiety and hopelessness, and 76% report a drop in household income amid rising costs of food.

• One of the lessons learnt from the Ebola outbreak in 2014 is that refocusing existing resources to the epidemic response is not efficient. If the resource are diverted towards to fight against the COVID-19 pandemic, it may hamper the provision of critical humanitarian assistance and have dramatic consequences on the fight against other epidemic such as cholera, malaria or HIV/Aids for instance.

• NGOs (including UK charities) are essential to the COVID-19 response because of their significant presence in the many fragile contexts and their extensive local networks.

Over-arching recommendations to the UK government:

• Ensure a principled and inclusive response
• Mobilise all diplomatic channels to ensure unimpeded humanitarian accesss
• Uphold commitments made in the DFID Disability Inclusion Strategy, including supporting the roll-out of the Inter-Agency Standing Committee guidelines on Disability Inclusion and the collection of disability-disaggregated data
• Scale up fast-tracked and dedicated funding to front-line humanitarian NGOs. 
• Immediately provide blanket flexibility measures across DFID’s entire portfolio of grants and contracts, rather than the current grant and contract by contract approach.
• Facilitate organization survival through measures such as forgiveable loans and stabilization funding. One of DFID’s greatest assets is its partners, and it is now more than ever that partners need support to survive, so they can respond to COVID-19, but also to continue to respond to humanitarian crises and alleviate poverty today and in the future. 
• Allow for additional costs to enable NGOs to assure duty of care

II-                          Humanitarian impacts of COVID-19 outbreak in emergency settings

1. At the time of the COVID-19 outbreak, 167,6[1] million people were in need of humanitarian response around the world, among which 70,8[2] million are displaced. COVID-19 is exacerbating humanitarian needs in countries that are already facing humanitarian crises.

2. This table gives a quick overview of some humanitarian crisis affected by the COVID-19, facing already huge needs because of the protracted crisis they are facing since many years, but also the number of displaced person within this crisis[3].

3. These countries, often affected by conflicts or disasters, are ill prepared to respond to the outbreak because of fragile health systems.
1. In Yemen, only 51%[5] of health centers are fully functional, the country’s infrastructure has been devastated by five years of conflict, leaving little capacity to respond. 19.7[6] million people are in need of healthcare and there are only 10 health workers per 10,000 people[7].  There is limited availability of medicine, equipment and personal protection equipment and only two testing sites in the country (Sana’a and Aden).
2. In Syria, after 9 years of conflict, the health system across the country is also devastated, with a lack of intensive care unit (ICU) capacity, of general equipment and of trained medical staff.  In the North West, 85 attacks on health facilities have been reported last year alone. There are 105 ICU beds in Idlib province with only 30 ventilators to meet the needs of the 3.2 million people in Idlib. Over 95% of the time these beds are already occupied by patients, meaning that there are few, if any, beds available for COVID-19 patients. NGOs face the same concern in North East of Syria. At the end of 2019, no district in the northeast met the emergency threshold of at least 10 beds per 10,000 people and just one district had sufficient doctors, nurses, and midwives to meet the emergency threshold of a minimum of 22 health care workers per 10,000 people. In Government controlled areas, it is estimated that there are only 325 ICU beds across Syria (with Deir ez-Zor having none) and that the Syrian health service has a maximum capacity to deal with 6,500 cases[8].
3. While Myanmar is facing a lack of ICU capacity, health facilities in Bangladesh are either unable to meet current caseloads and the hilly terrain and long distances act as a major physical barrier to access health care for individuals with mobility challenges.
4. In Burkina Faso, 135 health centers were closed in the last year, severely weakening the health system. There is currently only one hospital with 500 beds and only one single testing laboratory in Bobo-Dioulasso. In Mali, the country’s infrastructure has seen insufficient investment during years of conflict, leaving little capacity to respond. There is limited medicine, equipment and personal protection equipment available and only one respirator for the whole country. In addition, across the Sahel, the situation is also highly worrying in terms of food security.

4. Displaced populations face an increased risk of contracting the virus. More than 70 million persons globally have been forced to flee their homes, of which more than 29 million are refugees. 84% of these refugees are being hosted by low or middle-income countries where the health systems are weak and water and sanitation facilities overstretched. In a survey of internally displaced people carried out by HI teams in Somaliland, almost half of respondents report not having access to essential items to protect themselves from the illness (sufficient water, soap, masks, space to keep social distance). Around the world, most refugees and internally displaced persons find themselves in places that are overcrowded or where public health and other services are already overstretched, which make them highly dependent on the provision of humanitarian support and with a heightened risk of being affected by COVID-19. 

5. By adding pressure on health systems which are already not capable of responding to “ordinary” needs, COVID-19 will increase morbidity and mortality from other health conditions due to the reorientation of the funds towards the response to the epidemic[9]. Treatment of other pathologies and preventive health care, pre/post-natal care and safe delivery may be drastically reduced or stopped. Other epidemics are likely to develop if weak health systems are not supported. 

Key recommendations:

General recommendations:

1. Ensure that humanitarian principles guide the UK’s preparedness and response to the pandemic. For instance, equal access to impartial and inclusive assistance will be a key to keep humanity at the center of this response. The response to COVID-19 has to be centered on people and their needs first, prioritizing those most at risk, without any discrimination or stigma. 
2. Ensure that International human rights law, refugee law and the Convention of the Rights of Persons with Disabilities is guiding the humanitarian response and the efforts that will be necessary for the reconstruction. The UK should ensure its relocation activities are increased to protect refugees.
3. Mobilize all its diplomatic means, at every bilateral and multilateral opportunity, to :
1. Systematically condemn any breach to a full and unimpeded humanitarian access in countries that are already affected by a humanitarian crisis and in newly affected countries. For instance, condemn the recent restrictions imposed on access to Cox Bazar that is currently happening.  

• Systematically condemn any attacks on humanitarian and health workers to ensure humanitarian workers do not become a target while they conduct the humanitarian response to COVID-19 pandemic.

4. Facilitate the movement of goods and humanitarian personnel by supporting with financial and logistical means the creation of open corridors
5. Revise sanction regimes affecting and anti-terrorism laws that affect the supply and transportation of humanitarian goods 
6. Act as a leader to coordinate and ensure efficiency of the response, especially when it comes to supply chain management and movement of people based on the experience of the management of the Ebola crisis

III-                         COVID-19: exacerbated impacts on persons with disabilities

1. The COVID-19 pandemic heightens the risk of exposure, complications and mortality rates for specific vulnerable, marginalized and most at risk groups, including older persons, persons with disabilities, persons living with a chronic disease, migrants, refugees, internally displaced persons, mine/ERW survivors etc.

2. These vulnerable groups already face significant barriers in accessing health care and other services in many countries, due to general stigma and discrimination, lack of accessibility, limited healthcare services capacity and limited awareness of health staff. These barriers may become even more prominent during a health crisis like the COVID-19 pandemic.

3. Many persons with disabilities are either older or have underlying health conditions that increase the risk of infection and serious complications from COVID-19 (i.e. weak immune response, respiratory dysfunctions and other impairments or conditions). In contexts of conflict and acute humanitarian crisis, where prevalence of disability is higher this may mean a disproportionate impact of COVID-19. For example, in Syria 27% of the population, aged 12 and above, are persons with disabilities[10], a figure far exceeding the 15% prevalence rate for the world population, and 94% of men and 99% of women over the age of 65 also live with a disability.

4. Persons with disabilities may have greater difficulties in accessing prevention messages due to inaccessible communication. In Philippines, half of the youth with disabilities surveyed (18-39 years old), from Manila and Jakarta, need more accessible information about COVID-19 and community quarantine: 41% in Manila, 53% in Jakarta. 49% in Manila and 35% in Jakarta also need health support such as medicines, access to hospital care, and medical consultation.[11] More difficulty implementing preventive measures are also faced due to limited access to clean water/sinks, and repeated exposure and therefore need for regular disinfection of assistive technologies and devices. Applying social distancing is hard or impossible for those who rely on physical contact with the environment or support persons. For some people with disabilities, understanding prevention messages will be more difficult.

5. Persons with disabilities are already feeling the mental health impact of COVID-19. In Nepal, in a survey of almost 700 people with disabilities, 29% reported mental health impacts such as increased anxiety and hopelessness[12]. 

6. Also, in the current circumstances, persons with disabilities, persons with chronic diseases and older persons face further risk of isolation and exclusion, as social support services and networks, including personal assistance, on which some rely on for their daily living, are cut or interrupted. As pointed by Catalina Devandas Aguilar, UN Special Rapporteur on the rights of persons with disabilities, “containment measures, such as social distancing and self-isolation, may be impossible for those who rely on the support of others to eat, dress and bathe”[13].
7. As over-stretched health systems redirect services to COVID-19, there is a risk that people will suffer increased complications and mortality from pre-existing conditions such as diabetes, heart disease, etc. In Nepal, 27% of surveyed people with disabilities report an interruption of medical and assistive device services and 17% in the provision of therapeutic services[14].

8. Moreover, specific vulnerable and marginalized groups, including persons with disabilities, persons with chronic illness, and older persons, were already vulnerable due to socio-economic exclusion or life in overcrowded settings, and are therefore likely to be hit harder by the reverberating effects of the pandemic such as economic losses and absence of protection mechanisms. They are more exposed to an economic shock, because they are already excluded from the informal and formal economy[15]. Yet, much of the global population does not benefit from any forms of social protection[16]. The lack of social protection results in people not being able to reduce or interrupt their income generating activities and exposing them disproportionately to COVID-19. In Nepal, the lockdown has already negatively affected the livelihood of the most vulnerable population: 76% of surveyed beneficiaries report a decrease in family income[17].

9. In 2015, in a study conducted by Handicap International (former name of Humanity & Inclusion), 75% of people with disabilities believe they are excluded from humanitarian responses to emergencies like natural disasters and conflict. According to the study, three-quarters of 484 people with disabilities said that they did not have adequate access to basic assistance such as water, shelter, food, or healthcare.[18] Even though inclusive humanitarian action has made some progress since then, it is unfortunately still not enough to consider that persons with disabilities are adequately included within humanitarian response.

Key Recommendations

1. Ensure that DFID’s response follows a comprehensive approach to COVID-19 preparedness and response plans, encompassing the health, social protection, education, WASH, and other sectors and establish cross-sectoral collaboration across governmental services/branches and with civil society organisations. This should include the use of multi-purpose cash assistance when the market is adapted.
2. DFID has committed to rolling out the IASC Guidelines on Inclusion of Persons with Disabilities in Humanitarian Action in its Disability Inclusion Strategy Delivery Plan. This welcome step must be scaled up in the COVID-19 Response[19].
3. DFID should also follow, and encourage implementing partners to use the WHO considerations on disability during the COVID-19 outbreak[20], to ensure the rights and needs of persons with disabilities are met in operational plans.
4. DFID has committed to working with Organisations of Persons with Disabilities (DPOs) in its Disability Inclusion Strategy and should encourage country teams and implementing partners to engage with DPOs as well as representative organisations of women and the older persons to design inclusive response to the COVID-19 pandemic and to deploy awareness raising action.
5. DFID should ensure its funding of awareness campaigns promotes inclusive information on COVID-19 prevention and response through a diversity of accessible formats with use of accessible technologies, so as to leave no one behind. Public communication should also avoid stereotyping messages and images.
6. As part of its Disability Inclusion Strategy, DFID funded HI to develop a toolkit on the use of the Washington Group of questions to collect disability disaggregated data in humanitarian settings; DFID should ensure that this toolkit is systematically being used by all implementing partners[21].

IV-                        Scaling up and adapting the response: NGOs as essential actors

1. The global health and economic crisis caused by the pandemic involves immediate response to emergency needs but will also create a need for long-term support to low and middle income countries. 

2. In the current circumstances, humanitarian organisations and UN agencies have the duty to continue their lifesaving and protection activities, by adapting their programs to avoid the transmission of the virus. Enabling international non-governmental organizations to provide a principled humanitarian response in many countries simultaneously will be key to the containment of the pandemic.  

3. However, NGOs are affected by the economic crisis worldwide, but also by all the measures states are taking to prevent the circulation of the virus. Border closing, limitations of movement are impeding our capacity to operate and consequently have both the economic effect on the viability of our organization and limit our ability to respond at scale.

4. This pandemic is of exceptional scale. To face this current collective challenge and to ensure that international solidarity will not pay the price of domestic priorities, NGOs, International agencies and donors collectively need to implement coordinated response in compliance with the humanitarian principles.  

5. Local and international NGOs, including UK charities, are on the front-line of the response and already present amongst affected communities. HI is already responding to COVID-19 where possible, in our 55 countries of operation. Staff, operational partners and prepositioned stocks are available to respond to the crisis. NGOs have the capacity to scale up intervention on the field and this has been already demonstrated in the response to different epidemic in the past.  But they are facing a challenging environment: 
• Protection from the virus: Containment measures implemented by the governments of the countries we operate in limit our ability to deliver. In many cases (such as Jordan, Sierra Leone) NGO staff are not considered key workers and do not have authorization to move.  
• Most of our in-county capacity is tied to existing grants and contracts. While we welcome the ability to negotiate flexibility in each grant and contract funded by DFID, this is time-consuming, costly and leads to inconsistency, slowing down our ability to respond.
• Decreases in voluntary income are reducing our ability to cover core costs
• The furlough scheme, while appropriate for some organizations, is not relevant when team members are needing to work, but we are struggling to pay the costs of salaries.
• Uncertainty about the availability of new funds: while we welcome DFID’s funding announcement made on 12th April, £20 million for the NGO response is inadequate, considering our essential role as front-line key workers. 

7. In these contexts, the spread of the pandemic has an impact on ongoing humanitarian operations mainly because it limits the access to already affected population who are in dire need of aid. Programs are being stopped and/or adapted to the necessary prevention measures to guarantee the safety of the already affected population and the staff.  While humanitarian cargo continues to be allowed in many contexts, any disruptions to imports and medical supply lines could prove life threatening. New barriers resulting from the pandemic add up to the already existing barriers, challenging even more humanitarian access. Sending additional staff and goods to affected areas is essential for the implementation of an appropriate humanitarian response yet impossible today. Moreover, humanitarian staff is being targeted in some situation being perceived as vector of transmission of the virus. Attacks on humanitarian aid workers might increase in time of pandemic and reduce their ability to provide essential services. Of particular concern, all staffs in charge of logistic and logistic facilities such as airports, storage facilities are at risk of being targeted.

Key Recommendations

1. DFID should scale up its funding to front-line humanitarian NGO.  These funds need to be fast-tracked and dedicated for a global response.

2. DFID should immediately provide blanket flexibility measures across its entire portfolio of grants and contracts, rather than the current grant and contract by contract approach. This should include:
1. Pivoting funding to meet the changing needs
2. Payment in advance
3. Relaxation of payment by results requirements
4. Continuing funding of core costs even when programmes are slowed or stopped due to containment measures enforced by local governments to preserve operational capacities in adapting programs and resuming activities when the restrictions will be lifted
5. Cost-extensions

3. DFID should support organization survival through measures such as forgiveable loans, and stabilization funding. One of DFID’s greatest assets is its partners, and it is now more than ever that partners need support to survive, so they can respond to COVID-19, but also to continue to respond to humanitarian crises and alleviate poverty today and in the future.

4. DFID should allow for additional costs to enable NGOs to assure duty of care (procurement of personal protection equipment, increased costs of health and mental health support for our staff, relocation costs, etc), an easy way to do this would be to increase the NPAC (non-project attributable costs) rate.
5. DFID should influence the Treasury to adopt a flexible furlough model for charities, for example, enabling charities to part-furlough staff, or pay part of staff salaries while still allowing them to work full-time.

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