My Presentation to the UWI Disability Conference

The full version is being peer-reviewed for publication but it is a shame to waste this, so here is the “short” 20-minute version for the benefit of anyone interested in disability and health development. Plus a few comments on the conference so far.

The conference is incredibly good, with interesting presentations by good presenters. The opening ceremony was particularly inspiring, with senior figures from across the Caribbean. Of the presentations, I think the one that used video worked best, particularly as it included testimonials from several people with disabilities. I deliberately didn’t use Powerpoint in mine (and rarely do unless I have a clever diagram to show). This is because many people can’t see the slides. It is important not to lose the ability to be able to present without them. If you do use them they need to be a slight enhancement, used largely to aid the performance, rather than a means of conveying the information. It’s a communication. You need to think about how best to get your message across. There were a few people at the conference who I know can’t see and about another 100 on-line, who may have just been listening in.

A couple of other minor points is that I was on Zoom, but had YouTube running silently on the PC. I noticed that I was still being broadcast on YouTube, even when I wasn’t appearing on Zoom. My constant squinting to see the chat messages looked a little strange and may have appeared to be a reaction to something someone else was saying. I will watch my part back at some point, to just see myself being signed in ASL. The interpreter deserves special praise given how quickly I speak and how many consonants I swallow.

This version is 2,500 words, but it’s here for my benefit really, and I don’t expect you to scroll down any further. Unless you are really interested.

“Good morning, as you heard. My name is Craig Brewin and I’m the Head of Campaigns for the Montserrat Association for Persons with Disabilities  I should probably also add that I am also human guide to my partner who is the president of MAPD, so my interest in disability is not just professional.  And it is an incredible honour to be able to discuss these issues in such esteemed and knowledgeable company, and with a wider group of friends.  

My Presentation is specifically about Montserrat and the specific problems that arise from it being a British Overseas Territory, but it is to some degree relevant to all the British Overseas Territories, particularly those in receipt of overseas development aid. Many of the issues we need to be addressing here will be familiar to all of you.

I’m going to be talking about health development disability and international; law.  My presentation asks and answers a specific question. Who is responsible for ensuring the issues of health inequalities, particularly in relation to disability, are properly addressed in the rebuilding of health services in Montserrat?

At the moment, no one is taking responsibility. In fact, during the recent budget debate one of the Government Ministers said it was our responsibility. “Our” being the Montserrat Association for Persons with Disabilities. So here I am.

There are a few abbreviations in my presentation, but just to save constant repletion I mainly refer to the British Overseas Territories as the OTs, so bear that one in mind in particular.

Montserrat is dependent on British aid to support its recurrent budget. It is also embarking on a significant redevelopment of its infrastructure, which was destroyed by Hurricane Hugo, and the volcanic eruption in the 1980s and 90s. . It is receiving funding from the British Government, the EU and the CDB, and although disability issues are included in the funding agreements, addressing them is not a condition of the aid, and projects are being delivered without disability issues being considered.

Rebuilding Montserrat’s health system has been slow, and there is still no identified basic package of care on the island. Also, the charging system is inefficient, and charges are inconsistently applied. Private insurance arrangements, for example,  exclude persons with pre-existing conditions and are subsidised primarily for civil servants, who constitute around half the islands working population. 

A recent consultancy report recommended that a National Health Insurance approach be introduced, but as with many current developments, there is no framework relating to disability issues that can be used guide the development of new facilities and policies.

A recent social impact report commissioned by the CDB concerning the new port construction project highlighted the level of discrimination faced by persons with disabilities in Montserrat and the lack of legal protection. it is worth quoting at length.

It says “The Convention on the Rights of Persons with Disabilities seeks to ensure that people with disabilities have access to the same rights and opportunities as everybody else. The CARICOM Regional Organization for Standards and Quality (CROSQ) requires full accessibility of facilities, with which Montserrat, as a CARICOM associate member, should be compliant. However, there are no legal or policy provisions to secure these rights in Montserrat. Therefore, many public sector buildings are fully not accessible, and do not have fully accessible washrooms. When people arrive at the ferry terminal and beyond into Montserrat, they should be able to access the restaurants, bars and any other building that they choose to as part of their visitor experience. All persons with disabilities in Montserrat should be able to do so. However, currently without adequate provisions, there is effective discrimination against persons with disabilities” in Montserrat. You can find that report on the Government website.

There has been no formal response to this assessment from the Government, but it supports the conclusion of studies by UNICEF and Mott MacDonald, who were consultants engaged by the Government to review the health system in 2017. These showed that Montserrat’s health system is riddled with discrimination in both the range of services it provides and how it is funded. The UK Government has described the cost of medevacs as potentially “catastrophic” for some. Attempts to rectify this have stalled, and this has not been helped by Montserrat’s unique legal and constitutional status. There is no protection for persons with disabilities in the Montserrat constitution, and Montserrat is not signed up to the UN Convention on the Rights of Persons with Disabilities. In addition, there is no disability legislation in place.

Montserrat society is in poor health. Several health indicators are good, but over half of all deaths in Montserrat are caused by non-communicable diseases. Nearly half of all adults visiting a health facility have diabetes, and a quarter has diabetes and hypertension. In addition, 66% of all hospital admissions are due to diabetes, hypertension, or both. The figures mean that most people who use health services in Montserrat have a disability.

The prevalence of diabetes in adults in Montserrat was reported to be 14% in 2020. However, this is believed by the Ministry of Health to be underreported. The evidence of undiagnosed diabetes cases suggests a significant group of people whose ongoing care and monitoring needs are not being met through the current community clinics. Their view is that this is likely to be repeated across other non-communicable diseases. In addition, it is anticipated that as the population ages and, with increasing trends in obesity, the proportion of the population with NCDs will increase. Consequently, preventing and tackling NCDs, particularly diabetes and hypertension, needs to become an essential focus of the health service.

Total expenditure on health in Montserrat is only around 13% of total government expenditure, which is below the global average of 15.5%. Although the volcanic eruption in Montserrat was over 25 years ago, the only hospital on the island is a converted school with a limited range of facilities. The hospital provides casualty, medical, surgical, obstetric and paediatric services, but each remains vulnerable, and the range of services is small.

The planned infrastructure programme for the island includes a new hospital as part of an overall Health Project. This is designed to achieve a better balance of prevention, primary and secondary care, create universal health coverage, and transform how health services are funded on the island. However, there is a risk that the lack of a disability framework will mean that the project will not meet the needs of residents or deliver the UN Sustainable Development Goals. There is clear evidence of this already.

Good health helps people escape from poverty and provides the basis for long-term economic development, and the World Health Organisation has said that progress towards Universal Health Coverage will ensure progress towards other health-related targets and other goals. Protecting people from the financial consequences of paying for health services out of their own pockets reduces the risk that people will be pushed into poverty because unexpected illness requires them to use up their life savings, sell assets, or borrow – destroying their futures and often those of their children.

However, the British Overseas Territories are caught in a disability paradox. A new human rights-based disability strategy for its overseas development aid, was adopted by the UK Government, earlier this year. As well as the adoption of a human rights approach to disability, this includes the statement that its Foreign Office,(the FCDO) will “ensure disability rights are embedded in UN General Assembly and Human Rights Council resolutions.”

This may appear to give the UK the moral high ground, and the ability to claim global leadership on the issue. But the strategy does not apply to the Overseas Territories. Responsibility for disability issues in the OTs is devolved to the OTs themselves under the constitutional settlement of 2012, The OTs are not only exempt from the UK ratification of the CRPD, they are also exempt from the disability strategy that underpins its overseas aid. This is British taxpayer money governed by British law.

In fact, the FCDO admitted earlier this year that it had not addressed a specific General Assembly Resolution, passed in 2020 that called upon it to work with the Government of Montserrat to roll out the UK’s ratification of the CRPD. This is the key issue in this presentation, and one for which a solution is proposed.

The issue has tangible implications. For example, in 2022, the GoM appointed architects to design a new hospital building before the critical issues relating to equal access to the health system were addressed. Also, the complications around responsibility for health are not new.

A decade ago, the UK Department of Health published a document that set out how health provision the OTs fits within the UK’s Global Health Strategy. The report also identified a need for a review of health financing, an assessment of secondary and tertiary care on- and off-island, and the quotas placed on access to the UK’s National Health Service.

More recently, the UK Parliament’s Foreign Affairs Committee published a report that said it believed that health issues are “an important test of the FCDO’s ability to fight the OT’s corner.” It considered evidence relating to health issues from several OT citizens, particularly on the issue of access to the NHS. This included one who told the committee that “a British citizen’s life chances are diminished simply by residing in a BOT.” In a written submission, another described the NHS quotas, as “inexplicable”, mainly because “the overall number of persons in the OTs who will require such attention is minuscule.”

The 2012 White Paper, which sets out the devolved responsibilities of OTs, covers both aid-dependent and non-aid dependent territories. It says, “we believe that the fundamental structure of our constitutional relationships is the right one.” And given the intention that  “powers are devolved to the elected governments of the Territories to the maximum extent possible ” this includes human rights issues relating to disability. 

 Potential deviations from this settlement are noticed and, in some cases, there have been accusations of constitutional overreach and “modern colonialism through the back door.” But it does weaken the profile of disability issues in the aid  strategy

But it means disability issues within the management of overseas aid will have to be addressed within the current constitutional settlement.

Leadership on disability issues within the developing OTs is becoming an international issue and has reached the attention of the UN. For example, the Committee on the Rights of Persons with Disabilities stated in 2017 that “it observes with concern the insufficient incorporation and uneven implementation of the Convention across all regions, devolved governments and territories” and that the UK should “strengthen its efforts to extend the Convention and support its implementation in the Overseas Territories”.

The 2019 mission to Montserrat by the UN C24 Committee led directly to the 2020 resolution at the General Assembly that called upon the UK to assist Montserrat in preparing for the extension of the application of the CRPD to the island.. Also, to report progress to the General Secretary annually.  The UK has not done this.  

The Island Rights Initiative Think Tank has said that in its view: “In order to demonstrate a genuine commitment to ensuring that basic standards of human rights in the BOTs are the same as those in the UK, the UK Government should be prepared to extend all its international human rights obligations to all the OTs as a matter of principle.

This would provide an incentive for ensuring that standards are met and would allow the populations of the OTs to challenge failures to protect or respect their human rights through the courts and international oversight mechanisms.” This approach has been used before, particularly in the Caribbean Netherlands, and it resulted in a substantial increase in funding to the territories to improve standards. Maybe the aid dependent OTs should consider pressing for this.

Health inequalities, particularly relating to disability, will not be addressed systematically without commitment and a clear policy framework. But, I can make the case that Montserrat already has one, and that it’s not complied with.

Arguably it also has a compliance lead. The Programming Document for the EDF Funding from the EU, says this responsibility sits with a designated Technical Authorising Officer who is required to ensure that EU standards and requirements are met. This is identified as the Financial Secretary.

Each donor supporting Montserrat’s development has specific funding conditions, which link to the SDGs, the European Convention on Human Rights, the CRPD, and regional requirements. There are governance arrangements already in place to deliver the Montserrat projects. There are also clauses in the Labour Code related to disability, which should apply to employment at the new hospital.

Constitutional issues should cease to be a constraint on ensuring disability issues are addressed in the development of health services in Montserrat. In many cases, compliance with standards that have already been accepted or developed locally could be enough. An embryonic disability framework exists. Maybe it is more than embryonic.

If someone, like a researcher working for the Montserrat Association of Persons with Disabilities were to trawl all the legislation and funding agreements, and pull the components related to disability together into a single document, it would create a powerful statement of intent. For example, the EU’s standards state: “Economic and social development of the OTs should aim at attaining social welfare and inclusion, in particular for persons with disabilities, bearing in mind the principles of the CRPD.”

Montserrat’s aid-funded capital development is overseen by a single steering group, including politicians and civil servants from the FCDO and the Montserrat Government. Therefore, a single framework that combines all the funding requirements monitored by this group, would not risk any accusations of constitutional overreach. The single framework includes the following. 

1. The FCDO Business Case for Montserrat’s aid which says  Government services should focus on the most vulnerable, including the disabled” and that “the new capital programme will adopt best practice for disability-friendly infrastructure”.
2. The Montserrat Labour Code 2012 provides for equality of treatment in employment, irrespective of an employee’s disability.
3. It states that “disability” “shall not constitute a valid reason for termination of employment or other forms of discipline”.
4. Also, that an employer must make reasonable adjustments
5. The Building Code requires all buildings to have a certificate of compliance with the ADA.
6. CROSQ requires the accessibility of facilities
7. The Montserrat Constitution Order states that “no person shall be treated in a discriminatory manner in respect of access to any place to which the general public has access”.
8. The 2012 White Paper says that in respect for human rights the ” Territory Governments meet the same high standards as the UK
9. The EU says “Economic and social development should aim at attaining social welfare and inclusion for persons with disabilities” and in respect of Montserrat, “attention must be paid to the most marginalised and vulnerable groups.”

This is a lot to ignore. But my paper shows that the significant health inequalities in Montserrat are proving difficult to address. One hindrance is a lack of a clear lead on disability issues, and this stems from constitutional issues and the lack of clarity in the relationship between the 2012 White Paper and the FCDO’s  Disability Strategy in respect of its overseas aid to the OTs.  Given this particular time in Montserrat’s history, there is the possibility that planned developments could entrench existing inequalities rather than comprehensively address them.

But the GoM has accepted the funding conditions of several donors, which includes the requirement that money be spent in accordance with the provisions of the CRPD, even though Montserrat is not signed up to it.

Coordinating the funding requirements into a single framework that all projects should comply with, should not be a constitutional issue. It’s bigger than that. The single framework of funding conditions could support not only the capital programme, and specifically the new hospital, but also the development of the Universal Health Coverage on the island and the arrangements to fund it.”