The Economic and Social Commission for Asia and the Pacific is the regional developmental arm of the United Nations. There are over 650 million persons with disabilities living in the region. In 2012, member countries, including Pakistan, launched the new decade of persons with disabilities from 2013 to 2022, adopting the Incheon Strategy to 'Make the Right Real', based on the Put Convention on the rights of Persons with Disabilities" and aimed at accelerating the disability inclusive development with 10 measurable goals and targets. The year 2017 marked the mid-point of that decade at which point member countries were to submit the Government Members Report on the Implementation of Incheon Strategy. The ambiguity in usage of terms, variable definition of disability, and use of impairment screens in population census of Pakistan has resulted in flawed data and underreporting of persons with disabilities. Pakistan provided data on only 13 of the 30 core indicators as part of its midpoint review. There is lack of awareness among ministries regarding the Incheon Strategy implementation.
Keywords: Disability, Persons with disabilities, PWDs, ESCAP, Incheon Strategy, Pakistan.
The Economic and Social Commission for Asia and the Pacific (ESCAP) is the regional developmental arm of The United Nations (UN) consisting of 53 member and 9 associate member countries, including Pakistan. According to ESCAP, there are over 650 million persons with disabilities (PWDs) living in Asia and Pacific, and from October 29 to November 2, 2012, the members of the ESCAP gathered in Incheon, South Korea, launching the new decade of PWDs, from 2013 to 2022, and adopting the Incheon Strategy to 'Make the Right Real' for PWDs, comprising 10 goals, 27 targets and 62 indicators. The Incheon strategy is based on the Convention on the rights of Persons with Disabilities (CRPD), which is the first international disability-specific legal treaty, intended to protect and fulfil the rights of PWDs. Hence, the Incheon strategy aims at accelerating the disability inclusive development with measurable time-bound goals and targets.1 It is imperative to point out that 2017 marked the mid-point of the decade. It was deemed mandatory for all member states to make the baseline data on strategy indicators available, by 2017, which was crucial to aid in tracking the progress towards the achievement of the set goals and targets. A high-level intergovernmental meeting was held to review the progress, but unfortunately the Government Members Report on the Implementation of Incheon Strategy submitted to UN-ESCAP by Pakistan was unsatisfactory and lacked data relevant to the 10 goals of the strategy and their implementation.2
It is anticipated that information of the progress will help in raising awareness regarding this issue and make data available to the general population and the authorities concerned so that relevant actions can be taken to achieve the goals of the Incheon strategy till 2022. The current study was planned to review and report the existing literature and evidence on the availability of data regarding the goals of Incheon strategy in the context of Pakistan.
A literature search was conducted regarding the goals of the Incheon strategy in the context of Pakistan, using numerous key words specific to every individual goal. The search was conducted in 3 phases over a period of 4 months, from November 2018 to February 2019, with specific focus on evaluating the steps taken for the implementation of Incheon strategy and areas deficient in its execution. An online literature search was conducted using electronic search engines, including PubMed, Elton B. Stephens Company (EBSCO) database EBSCOhost, Scopus, Google Scholar and Pakmedinet. Data published from 2012 onwards was retrieved, but in the absence of any relevant data, previously published data was also considered. The second phase of literature search consisted of retrieving the relevant data from newspapers and governmental and international organisations' websites. The third phase comprised searching from the relevant sources and bibliography of the relevant literature. The searched literature was reviewed by authors independently and conclusions were deduced collectively.
Goal 1: Reduce the number of poor persons with disabilities and increase jobs for persons with disabilities.
- Limited data is available regarding the lives and socioeconomic status of PWDs, especially pertaining to developing countries, like Pakistan.3,4 An analysis found that, utilising the expanded measure of disability in Pakistan, poverty rate was higher in PWDs (75%) in contrast to individuals without disability (68%). PWDs have limited access to education and employment prospects contributing to poverty, with only 29% of PWDs being employed compared to 52% individuals without disability, and 23% disabled employees versus 50% non-disabled employees in urban areas. Also contributing to increased poverty is the ratio of medical to total expenditure which was higher in households with a PWD (15%) compared to other households (12%).5,6
- In 2002, the National Policy for Persons with Disabilities was formulated by the federal ministries in Pakistan, focussing on vocational training, employment and rehabilitation of PWDs, and incentives were planned to be given to employers on hiring PWDs. In 2006, the National Plan of Action was designed to identify measures for effective implementation of the National Policy for PWDs.7
Goal 2: Promote participation in political processes and in decision-making.
- Observation of disability-inclusive electoral system is essential for addressing the barriers faced by PWDs, and for empowering them to serve effectively in leadership roles.8 PWDs in Pakistan have remained socially excluded from civic engagement and political participation, lacking legislation for the inclusion of PWDs in electoral and policy-level decision-making processes. The findings of a baseline survey conducted in 4 districts of Swat, Mardan, Malakand and Swabi revealed that majority of PWDs were unable to cast votes in the general elections of 2008 due to lack of facilitating environment and formal education prior to the electoral process. The findings of a study showed that 33 (8.1%) PWDs did not register their votes and 50 (12.4%) PWDs had no awareness about registration and their right to vote, and a total of 179 (44%) PWDs did not cast their vote among whom 100 (67%) were unable to go to the polling station.9
- As for the 2013 general elections, the Election Commission of Pakistan (ECP) launched a short message service (SMS) facility for checking registration numbers and polling stations location, resulting in a larger proportion of PWDs intending to cast their votes.
Goal 3: Enhance access to the physical environment, public transportation, knowledge, information and communication.
- In 2006, the Islamabad Declaration on Accessibility for Persons with Disabilities was passed which called upon architects and town developers to ensure that design of all public spaces, parks, buildings and walkways should meet the defined accessibility standards.10 Unfortunately, only a few government buildings have ramps, and even they are usually closed due to security reasons, and almost 90% of public buildings lack facilities for PWDs.11
- Also, PWDs face a lot of difficulty in accessing public transport12 because of poor vehicle access, terminal facilities and environmental conditions in Pakistan.13 Vehicle manufacturers are required to follow the 'inclusive design principles' by the regulatory authorities,14 yet adherence to such policies is not satisfactory. Based on the Government Members Report on the Implementation of Incheon Strategy submitted by Pakistan, the Ministry of Transport was not even aware of the Incheon strategy (Table-1).2
- The target of accessibility and usability of information and communication services was assessed by evaluating website accessibility, and it was found that the websites of the federal government were not constructed as per accessibility standards for PWDs.15 It is also reported that 50% of library websites of top Pakistani universities had issues with general accessibility and almost none of them was found to be PWD-friendly.16 Similarly, bank websites are also inaccessible for some disabled groups.17 The website of Pakistan Telecommunication Authority (PTA) was found to be the only one to have incorporated web accessibility standards for PWDs, and an interactive tool bar had been added for the facilitation of PWDs18 (Table-2).
Goal 4: Strengthen social protection.
- Similar to other countries, policies of Pakistan for PWDs are not designed adequately.19 Although Pakistan signed UN-CRPD in 2011, no concrete actions were taken by the government for its implementation.20 Quite recently, a bill to protect the rights of PWDs was introduced in the National Assembly which is in consideration for approval.21 A law named, Disabled Persons (Employment and Rehabilitation) Ordinance, has already been mandated in 1981 to tackle the issues of segregation and unequal employment rights for PWDs. According to this law, each government organisation must employ at least 2% of workforce from disabled population or pay same amount equal to the pay of such staff to the Disabled Persons Rehabilitation Fund. Amount collected in this fund will be utilised for the provision of scholarships and stipends, including provision of assistive devices and establishment of training centres, for PWDs.22,23
- As barriers to employment still exist due to perception of a PWD as an unproductive member of the workforce,24 lack of government policies to provide economically productive opportunity results in reinforcement of this opinion.25 After the amendments made in 1981 act in 2015, PWDs are now entitled to free medical and health facilities at federal, provincial, district and tehsil levels. Parents of disabled children will be provided with annual stipend from Pakistan Baitul Mal. Formulation of local bodies to evaluate and ensure its implementation is also a part of this act,26 and lawmakers are now taking a keen interest in protecting the social rights of PWDs.27,28
Goal 5: Expand early intervention and education of children with disabilities.
- In Pakistan, 43.4% population is aged <15 years, 30.4% is <10 years and 14.8% is <5 years.29 Unfortunately, no official statistics are available regarding the percentage of children with disabilities, let alone the access of healthcare amenities to such children. A study in 1995 screened 6395 children in Pakistan for disability, and 936(14.7%) children screened positive.30 It is a known fact that children with disabilities are at a greater risk of developing health-related issues and co-morbidities which can result in exponential health expenditure and are thus in a greater need of healthcare, with a study showing that 33.33% of the children with Down Syndrome aged <1year had congenital heart disease.31 Similarly, a study showed 34 (68%) of children with speech delay also had intellectual disability.32
- In terms of importance of early detection and intervention, a study on children aged 2-10 years with delayed milestones showed that 67% of the children were identified with a major radiological diagnosis, including leuko-dystrophy (30%), cerebral atrophy (16%) and congenital malformations (15%) on magnetic resonance imaging (MRI).33 Parents of Pakistani children usually do not seek early professional advice or intervention. A study in 2012-14 showed that the average age at the time of first visit for children with congenital foot anomalies was 4.47±4.89 years.34 Similarly, the average age at the time of radiological diagnosis in children with delayed milestones was found 5.24±2.48 years.33 Another study showed that even though impairment was noted as soon as 0-6 months of age in 33% children with hearing impairment, first professional advice was sought as late as 10-24 months in 35% cases.35 All these findings indicate towards the fact that even though early detection and management is crucial in terms of better prognosis and decreased disability, the average age at the time of first reporting is comparatively higher in Pakistan. There are numerous possible reasons for this delay, including lack of facilities and specialised rehabilitation centres in the country, lack of policy and focus of governing bodies for PWDs, and limited education.34
- A study on 6395 children aged 2-9 years determined the validity and reliability of '10-question functional screen tool' in Pakistani population, and the tool showed acceptable sensitivity ranging 84-100% for serious cognitive, motor and severe disabilities, but <80% for hearing and mild disabilities.30 Even though it is not appropriate as a clinical assessment tool,30 it can be very useful as a low-cost and quick screening tool for children with disabilities with slight modification in questions relating to hearing and vision.30,36 Lastly, lack of education also plays an important role in terms of early intervention in children with disabilities. A study on hearing impairment in children in schools of Rawalpindi, Islamabad and Lahore showed 32% of parents did not support the benefits of early detection and intervention.37
- In terms of education of children with disabilities, a survey in 1981 in Pakistan found 10 special schools for blind, 24 for deaf and 15 for children with mental retardation. In 1988, 10,373 children aged 5-14 years were enrolled in special schools; 7126 (68.7%) males and 3247 (31.3%) females. In terms of disability, 54% hearing-impaired, 24% physically disabled, 13% mentally challenged and 9% were visually impaired.38,39 The teacher-to-student ratio in schools for special children ranges from 1:14 in federal to 1:11 in provincial and 1:15 in non-governmental schools. A study pointed out that teaching skills and equipment in these schools was inadequate and in poor condition.38 By 1989, 45 special schools were reported with nearly 3500 students though no official document was available (Table-3).39
Nonetheless, there is no recent data available on this topic, which is the need of time in the light of the goals of the Incheon strategy, but the ministries of Health and Education are not even aware of the Incheon strategy.2
Goal 6: Ensure gender equality and women empowerment.
- Women with disabilities (WWDs) encounter twice the discrimination on account of both gender and disability.40 Equality challenges for WWDs have been reported worldwide, particularly in low- and middle-income countries (LMICs).41 The Global Gender Gap Report 2018 placed Pakistan at rock bottom in terms of women empowerment; being ranked 148 out of 148 countries. Furthermore, as per the Government Members Report submitted by Pakistan, the Ministry of Gender Equality is also not aware of the Incheon strategy, and perhaps that is why this picture of gender inequality still exists despite the number of key international, national and local commitments to gender equality and women's human rights.42 As per Pakistan's census report 2017, women make up 49% of the total population, and 50% of PWDs are women, of whom 70% live in rural areas with no or limited access to essential services.43
- To figure out equitable access of WWDs to mainstream development opportunities, like social, political and economic, official data is unavailable. However, some generalisation to WWDs can be made based on existing figures of gender disparities in terms of distribution of socio-political resources and economic status of women in general. According to the Economic Survey of Pakistan, 2017, literacy rate among females was 48% compared to 70% in males.44 Economic participation of females as legislators/managers is 2.9% and political participation is as low as 20.6%,42 with lack of participation of PWDs, specifically WWDs, in Pakistani parliament. According to the World Disability Report, 2011, WWDs faced barriers to access of reproductive and sexual healthcare information and services,45,46 and Pakistan has the 3rd highest burden of maternal and foetal mortality in the world, with a maternal mortality rate (MMR) of 178 per 100,000 live births.47 However, no such data is reported for WWDs. Moreover, practices of violence and abuse are common amongst WWDs, with higher level of sexual violence amongst intellectually-disabled women, highlighting the need for awareness.48
Goal 7: Ensure disability-inclusive disaster risk reduction and management.
- Pakistan is frequently exposed to climate-induced disasters with an increase in the rate of natural disasters in the last three decades, affecting 32 million people.49 Disasters impose inequitable influence on PWDs, thus precluding them to effectively participate in community. In addition to their vulnerability, disasters further increase exposure of PWDs to injury, death or loss of property due to physical restrictions, deficient infrastructure, coping abilities and absence of standard facilities, and are usually excluded from disaster risk reduction policies, plans and programmes.50
- The National Disaster Management Authority (NDMA), established under the NDMA Act, 2010, has made specific references for provision of relief and prohibition of discrimination against vulnerable groups.51 The National Disaster Risk Reduction Policy, formed in 2013, has significantly focussed on prevention, alleviation and preparedness aspects of disaster risk reduction, and recognised higher vulnerability in the form of disabilities at higher disaster loss.52 In May 2014, Gender and Child Cell of the NDMA published national policy guidelines specific to vulnerable groups during disasters, including PWDs.53 Other than national policies, enforcement of global policy instruments, like UN-CRPD (2008) and Sendai Framework for Disaster Risk Reduction (2015) are also playing vital roles. Efforts are also under way to mainstream disaster risk reduction (DRR) in education curricula at graduate and postgraduate levels as well as incorporation of updated DRR knowledge and practice.52 A study has reported that gender dimensions have been incorporated in Pakistan disaster management policy and guidelines, but these principles have addressed only immediate post-disaster period.25
Goal 8: Improve reliability and comparability of disability data.
- There is scarcity of reliable data regarding the prevalence and status of PWDs in various countries of South East Asia. The reports submitted by several national and international agencies, including the United Nations Educational, Scientific and Cultural Organization (UNESCO) (1999), the Japan International Cooperation Agency (JICA) (2002), and the United Nations International Children's Emergency Fund (UNICEF) (2003), stated the same. A few of the multiple issues contributing to lack of accurate, reliable and comparable data on disability in Pakistan include ambiguity in usage of terms, variable definition of disability used in census and survey questionnaires, narrow criteria for type of disability identifying only severe impairments, social stigma associated with disability leading to underreporting, and reporting errors due to respondent's bias.54 For most of the developing/underdeveloped countries, population census remains the only reliable source of data, but Pakistan, like all other developing/underdeveloped countries, adopts the Impairment Screen approach towards identifying and reporting of disability which always results in underreporting of prevalence figures as evident by the conflict between the population figures of PWDs reported in the 1998 census at 3.3 million and by UN-ESCAP at around 4.01 million. Thus, the disability prevalence given in 1998 census of Pakistan is considered to be an underestimation, with the likelihood of increased prevalence rates ranging from 2.5% to 10%.55,56
- Pakistan's failure in defining disability, and the fact that the Pakistan Bureau of Statistics (PBS) is not even aware of the Incheon strategy,2 together reflect lack of concern with disability, and, thus, lack of availability of statistical data, acting as a major barrier in policy-making and implementation of the rights of PWDs.22
- Another target of this goal is aimed at strengthening of disability-related data collection in member states to generate high-quality statistics, which is only possible if international standard approaches are adopted for national data collection.
Goals 9 & 10: Accelerate the ratification and implementation of CRPD and the harmonisation of national legislation with the Convention and advance sub-regional, regional and interregional cooperation.
- In 2008, Pakistan signed the CRPD and later ratified the convention in 2011. However, PWDs are still facing issues of marginalisation, discrimination and neglect, particularly in the economic sector, education, availability of resources and legal recognition. Hence, immediate action should be taken by Pakistan government and legislative bodies to accelerate the effective implementation of CRPD.57,58
- Moreover, multi-regional collaboration could be enhanced via contribution to the Asia-Pacific Multi-Donor Trust Fund established by ESCAP. As per the 2016-17 annual report by ESCAP, the Multi-Donor Trust Fund for Tsunami, Disaster and Climate Preparedness had obtained $15.5 million in funding from its member donor states, but Pakistan was not one of the contributing donors. One of the projects supported by this fund, namely Enhancing Tsunami Resilience in Pakistan, was directed towards creating awareness, warning and preparedness for disaster risk in the provinces of Sindh and Baluchistan. This was undertaken through a participatory process which involved multiple stakeholders, such as national and district level authorities, non-governmental organisations (NGOs) and local body (LB) representatives.59
Factors like ambiguity in usage of terms, variable definition of disability, and the use of Impairment Screens in population census have resulted in flawed data and underreporting of PWDs, which eventually leads to lack of emphasis and poor policy-making related to the subject of PWDs. Pakistan only provided data on 13 out of the 30 core indicators for ESCAP midpoint review in 2017. There is lack of awareness among the relevant federal ministries regarding the Incheon strategy and its implementation.
Conflict of Interest: None.
Source of Funding: None.
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