Sightsavers’ evidence to the International Development Select Committee inquiry on UK aid to Pakistan
- 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 developing countries. Our programmes also include working to ensure quality inclusive education, strengthen health systems and eliminate neglected tropical diseases (NTDs).
- Sightsavers is the recipient of FCDO funding in Pakistan, including programmes around eye health, inclusive education and disability inclusion.
- We welcome the opportunity to contribute to the International Development Committee’s inquiry on UK Aid to Pakistan.
Strategy, coherence and alignment
Are the UK's strategic aims for its Pakistan aid programme clear and appropriate?
- Sightsavers was very familiar with DFID’s work in Pakistan, and we felt that the strategic aims of the DFID programme were clear and appropriate. DFID Pakistan collaborated closely with the Government of Pakistan, most notably the health and education ministries and we felt that education and health sector reforms in the country and DFID Pakistan’s strategy were extremely well aligned.
- We welcomed the prominence and promotion of the DFID’s Disability Inclusive Development Strategy in Pakistan since its launch in 2018. Its influence was clear in early market engagements, call for proposals and programme strategies.
- However, given the recent changes in the aid budget and the merging of the FCO and DFID, we cannot yet say if the current aims for its Pakistan aid programme are clear and appropriate.
Focus and scale
How effective is UK aid in Pakistan in supporting its progress towards achieving the SDGs?
- Overall, Sightsavers believes that DFID was effective in supporting the Government of Pakistan in making progress towards the SDGs. The Ministry of Planning, Development & Reform (MoPDR) established a dedicated SDG section and support unit to monitor and to coordinate the implementation of the SDGs. DFID Pakistan and other development partners worked closely with this section to deliver the SDGs. Critically, DFID was also focused on supporting institutions to support the delivery of essential public sector services. This includes a focus on tackling corruption – addressing this issue is essential to ensure that progress made towards the SDGs are equitable and sustained.
- Again, we felt this support was particularly notable in the areas of health (SDG3) and education (SDG4). For example, DFID invested heavily in supporting education reforms in Pakistan – through the Punjab Education Support Programme II, DFID aimed to improve access, retention and the quality of education for all children in primary and secondary schools of Punjab Province. This has benefitted over 1.5 million children to date. Component 5 of this programme was financial aid to the Government of Punjab Special Education Department for an inclusive education programme to provide formal schooling opportunities to children with ‘mild’ disabilities.
- DFID support to Sightsavers in Pakistan contributed primarily to SDG 1 (end poverty in all its forms everywhere) and SDG 3 (ensure healthy lives and promote well-being for all at all ages). This included support for programming which focused on elimination of Trachoma. By its nature, trachoma is a disease of poverty. The trachoma endemic districts are amongst the lowest socio-economic populations in Pakistan, with limited opportunities to access services such as trachoma surgery and limited access to basic health hygiene enablers, such as education, soap, water, and latrines. At the heart of this support was ensuring that no one is left behind through our ongoing projects, with an emphasis on reaching women and girls (SDG 5), people in rural communities and people with disabilities.
- Since the merger, we have been able to carry on our work in Pakistan towards the SDGs. The recent focus has been on the integration of disability indicators in the national Sustainable Development Goals (SDGs) dashboard at federal level. The FCDO’s support to Sightsavers allowed us to participate in a consultation workshop including representatives from the federal and provincial SDG support units in October 2020. The workshop explored how data for indicators is currently collected and reported and identified that no disability data is being collected and no indicators are disaggregated by disability. We have worked to identify how indicators could be disaggregated and continue to work with the Ministry of Planning. The FCDO’s continued support in this area will be critical to ensure that disability data is collected at a national and provincial level.
- The UK’s ODA to Pakistan needs to be maintained to support achievement of the SDGs.
- The FCDO should strengthen and increase its collaboration with the dedicated VNR/SDG units within the Government, particularly at provincial level.
- The FCDO should continue to support engagement with the Ministry of Planning, particularly to ensure that the principle of leave no one behind is embedded into Pakistan’s delivery of the SDGs.
- The FCDO should publish a global health strategy paper to ensure that all FCDO support to the health sector in Pakistan, and more broadly, takes a coherent health systems strengthening approach.
To what extent is UK aid in Pakistan focused on the poorest, most marginalised and most vulnerable people in that country?
- We believe that DFID focused extensively on reaching the people who were the poorest, most marginalised and most vulnerable in Pakistan. Through their support on education, DIFD had a strong focus on girls and in the area of economic empowerment, there was an emphasis on empowering women with skills development.
- This focus also applied to DFID support to Sightsavers. Activities included (but were not limited to) training hospital management, health care workers and frontline government health workers on disability inclusion and gender mainstreaming, to increase their knowledge and skills, improve their attitudes and provide more inclusive services; conducting accessibility audits of partner hospitals; the collection of disability disaggregated data; and targeted screening camps for people who are marginalised. With DFID support, training manuals on Disability and Gender Mainstreaming were developed and national guidelines on Inclusive Eye Health were developed.
- Sightsavers has played an active role in the development of Integrated People Centred Eye Care (IPCEC) plans which was funded by UK Aid Match. The plans will provide direction to eye care sector for next 10 years. In Pakistan, the Inclusive Eye Health Task Force was established in 2018, with a role to develop country specific inclusive eye health guidelines that will be endorsed by National Eye Health Committee (NEHC). During a NEHC meeting at the end of December 2019, a unanimous decision was taken to develop inclusive eye health plans nationally and for each province, starting in the first quarter of 2020. Draft national and provincial inclusive eye health plans have been developed and approved by the national and provincial coordinators and endorsed by the Federal Secretary of the Ministry of Health. The NEHC and provincial eye health committees will be the custodian of the plans and ensure they are implemented as intended. However, ensuring adequate budget allocations and effective institutionalisation at all levels will require ongoing engagement.
- It is critical that UK aid continues to focus on the poorest and most marginalised people.
- We welcome the UK’s commitment on girls’ education. It is critical that this is followed on through in the allocation of ODA. The focus on girl’s education must also prioritise girls and boys with disabilities, as mentioned in the FCDO: disability update Progress against DFID’s strategy for Disability Inclusive Development which stated the new plan to improve access to and quality of government schools for over 35,000 children with severe disabilities in Pakistan.
- The FCDO should continue to implement DFID’s Strategy for Disability Inclusive Development in Pakistan as referenced and ensure the disability inclusion is systematically included across all UK aid programmes in Pakistan to ensure ‘no one is left behind’.
- The FCDO needs to ensure that the work carried out by DFID is continued and built upon. As an example, the FCDO should take steps to leverage the development of training manuals on disability and gender mainstreaming by adapting as appropriate and integrating this type of training into all FCDO funded activities in Pakistan.
- FCDO should support the Government of Pakistan to collect and analysis disability disaggregated data and leverage it in decision making.
How effective are the partners (NGOs, private contractors and multilateral agencies) through which UK aid is delivered in Pakistan?
- With DFID and FCDO, we have been able to work effectively in partnership around disability inclusion. One such partnership is the Pakistan Development Alliance (PDA). PDA is one of the largest civil society networks, playing the role of a watchdog on SDGs implementation status. PDA is made up of more than 250 civil society organisations from Pakistan. Sightsavers influenced PDA through a series of discussions to engage with Organizations of Persons with Disabilities (OPDs) at provincial and district level to introduce disability champions. This enabled Sightsavers to enhance the disability agenda in the national and provincial level discussions and consultation of SDGs implementation and planning processes.
- Sightsavers are also part of the Community Based Inclusive Development (CBID) Network. CBID is a national level disability network formed of provincial OPDs and CBOs/NGOs and was an important part of the Global Disability Summit in 2018. Our partnership has enabled us to achieve some significant advocacy milestones. We could influence the global equal world campaign of Sightsavers and this resulted in approval of the Pakistan Disability Rights Act, passed on January 10, 2020. This was strongly supported by engagement with DFID. The UK’s engagement and support for key policy processes has been, and should remain, a critical part of the UK’s bilateral development work.
- Another strong partnership is the National Forum of Women with Disabilities (NFWWD). NFWWD is a national forum being managed and led by disabled women leaders. The forum has provincial and district level chapters led by representative women with disabilities, who work with their peers to identify and empower other women with disabilities from the grassroot level. Sightsavers work with NFWWD to strengthen the capacity of local level self-help groups and small CBOs. Sightsavers partners with NFWWD to support their advocacy goals in Pakistan Through this partnership Sightsavers is collaborating with the Women’s Parliamentary Caucus to advocate for the rights of women with disabilities for inclusive education, decent employment, leadership development and skills development in vocational training programmes. NFWWD along with Sightsavers and other stakeholders took part in drafting the national disability bill that has been approved recently. It is critical that the FCDO works in partnership with grassroots organisations such as the NFWWD who can ensure that the voices of those most at risk of being left behind are heard in decision making processes.
What are the key risks (and mitigations) to the value for money, effectiveness and impact of UK aid projects and programmes in Pakistan?
A lack of investment in devolved governance structures
- The devolution of power from central to local governments has been an ongoing process in Pakistan since 2008, this process has been fraught with delays and significant challenges. These challenges should not be underestimated in terms of how they affect progress towards the SDGs generally and more specifically, the value for money, effectiveness and impact of UK aid projects and programmes in Pakistan.
- A specific challenge that arises is the lack of human resources and technical expertise at provincial level to make well-informed, effective decisions. This can result in the establishment of parallel systems to support the implementation of externally funded projects and programmes. This has the risk of undermining local institutions and exacerbating challenges.
- UK Aid should strengthen existing government institutions and structures by investing in capacity building of human resources at this level. UK Aid should ensure that their investments are made in alignment and collaboration with provincial governments. The FCDO should build in adequate time, as well as technical support, to their project timelines to ensure that projects and programmes are working with, and not bypassing, local government institutions and structures.
A weak health system
- While health outcomes are improving in Pakistan, the health system is inherently weak and it may struggle make significant progress towards UHC or to respond to shocks, such as a threat to global health security or extreme weather event. These weaknesses cut across the WHO Health System Building Blocks. For example, in relation to the health workforce, Pakistan’s recent Voluntary National Review recognises that the availability and quality of the health workforce is a critical challenge and needs to be increased from 1.45 to the WHO recommended 4.45 per 1,000 persons.
- The Government of Pakistan is making critical health sector reforms to address inadequacies in the health system, as well as introducing a health insurance scheme (Sehat Sahulat) as part of efforts to make progress towards UHC.
- Strong, resilient health systems require long-term commitment and investment from governments and development partners. The UK should continue to provide both long-term technical and financial support to the Government of Pakistan in support of their efforts to increase domestic health expenditure, strengthen the health system and make progress towards UHC.
Increasing levels of antimicrobial resistance (AMR)
- Increasing levels of AMR is a significant risk to addressing some disease areas in Pakistan and making sustained progress towards SDG 3 goals. For example, in Pakistan, Zithromax is the only remaining drug that typhoid is not resistant to, this has significant implications for treatment and mass drug administration efforts. Partners, including the Ministry of Health and WHO, are working on this specific challenge.
- The UK should continue to provide global leadership on the issue of AMR and ensure countries, such as Pakistan, have access to the technical and financial resources needed to address this challenge.
How has UK aid responded to the challenges of COVID-19 in Pakistan, and how effective has this response been?
- The COVID-19 pandemic has had a significant economic impact on South Asian countries, including Pakistan. The World Bank has estimated that the regional growth will fall to a range between 1.8 and 2.8 percent in 2020, down from 6.3 percent projected six months ago.
- The COVID-19 pandemic and the resulting economic and social fallout presents a serious threat to people with disabilities. Supported by the DFID and the FCDO, Sightsavers programmes in Pakistan focused their advocacy efforts to ensure that persons with disabilities were included during the COVID-19 emergency response.
- For example, our work around the COVID-19 pandemic helped to ensure people with disabilities were not unfairly excluded from the pandemic response. We made sure it was agreed that all written and verbal communication regarding COVID-19 response (medical, relief, any other announcement) be available in a variety of accessible formats and all quarantine spaces should be accessible for people with disabilities.
- In addition, with the support of UK aid, we were able to work with the national disability network (CBID) to develop locally approved guidelines for people with disabilities in COVID-19 in the form of short videos. We also worked with SEDA (national NGO) and Pakistan Association of Blind (PAB) and adapted the WHO’s considerations for people with disability during COVID-19 in Braille.
- Sightsavers also worked with the CBID secretariat on inclusion of persons with disabilities which resulted in a quota for people with disabilities in government led vaccination programmes and the provision of mobile vaccine programmes for people with disabilities and people over 80.
- We believe UK aid has responded well to the pandemic situation in Pakistan by allowing programme flexibility. However, we are concerned that the cuts to UK aid will have a detrimental effect on Pakistan’s ability to recover from the impacts on the pandemic, with particular risks for the poorest and most marginalised people.
For further information about this submission or any aspect of Sightsavers’ work, please contact Lauren West, Parliamentary Adviser, at firstname.lastname@example.org
IDC Inquiry Effectiveness of UK aid to Pakistan | May 2021
 This component ended in April 2020.
 Government of Pakistan (2019) Pakistan’s Implementation of the 2030 Agenda for Sustainable Development Voluntary National Review, page 30
 World Bank (2021) South Asia Overview