Hannah Kuper,2 Lena Morgon Banks,3 Mark T. Carew,4 Emily Eldred,5 Georgina Gaskell,6 Islay Mactaggart,7 Sarah Marks,8 Sara Rotenberg,9 Nathaniel Scherer10 and Tom Shakespeare11 12 13
Abstract People with disabilities experience stark inequities across the spectrum of development priorities. Yet they are rarely prioritised by development programmes. The poor evidence base for ‘what works’ for disability-inclusive development is a major challenge to taking action and advancing the meaningful inclusion of people with disabilities. The Programme for Evidence to Inform Disability Action (PENDA) was established to undertake high-quality impact evaluations to assess whether holistic approaches to disability-inclusive development improve the participation of people with disabilities in key areas of society (health, livelihoods, education). Through PENDA, 13 evaluations were implemented across 13 low- and middle-income countries. Impact evaluations are predominantly through the gold standard approach of randomised controlled trials. Each trial has a complementary mixed-methods process evaluation to better understand the findings and their implications. This article reflects on key considerations for undertaking impact evaluations of disability-inclusive development interventions, illustrated from the PENDA trials, and learnings to advance this research agenda.
Keywords disability, development, impact evaluations, randomised controlled trial (RCT), low- and middle-income countries (LMICs), process evaluation.
People with disabilities experience stark inequities across the spectrum of development priorities compared to others in the population, including with respect to poverty, health, education, and livelihoods (Cote and Banks 2025). These gaps arise because of disability-related stigma and other barriers to participation such as inaccessible infrastructure and facilities. Yet development programmes rarely prioritise, or even make efforts to include, people with disabilities, thereby reinforcing these inequities.
Micro-entrepreneur with disabilities, Kakuma refugee camp
Photo credit Imani Rugenge/Humanity & Inclusion
The poor evidence base for ‘what works’ to promote the inclusion of people with disabilities in development programmes is a challenge to taking action and achieving meaningful inclusion in disability-inclusive development. An evidence and gap map (EGM) of the available evidence from impact evaluations and systematic reviews on the impact of interventions for people with disabilities found that the literature was sparse and mostly focused on interventions in the domain of health (Saran, White and Kuper 2020). Three subsequent Campbell Reviews on the evidence for the effectiveness of livelihood, education, and social inclusion interventions respectively confirmed that there was little evidence and it was frequently of poor quality (Hunt et al. 2022, 2025; Saran et al. 2023). Moreover, the interventions evaluated almost exclusively were individually targeted to people with disabilities (e.g. to improve skills for learning), rather than tackling structural or systemic barriers to their participation (e.g. improving the accessibility of schools).
The Programme for Evidence to Inform Disability Action (PENDA) is an eight-year research programme, which started in 2018 and aims to help address the need for high-quality evidence on ‘what works’ to achieve disability-inclusive development. PENDA is based at the London School of Hygiene & Tropical Medicine (LSHTM) and funded by the United Kingdom’s Foreign, Commonwealth & Development Office (FCDO). LSHTM has collaborated with partners in low- and middle-income countries (LMICs) to undertake 13 evaluations across 13 countries to assess the effectiveness of interventions to improve inclusion in livelihoods, health, and education for people with disabilities. PENDA prioritised (1) interventions that address systemic barriers to inclusion, rather than targeting individuals, (2) gold standard randomised controlled trials (RCTs) with complementary mixed-methods process evaluations, and (3) high-quality research approaches, including sufficient sample size, the use of standardised tools, and equal partnership with people with disabilities (e.g. inclusion as researchers, advisers, and study participants) as well as academics from LMICs (e.g. supporting LMIC partners as lead/senior author on publications, establishing a PhD scheme for academics with disabilities). We hope these actions will help to build capacity for disability research in LMICs, as well as support the next generation of researchers with disabilities.
Recent estimates suggest that there are at least 1.3 billion people with disabilities globally, making up 16 per cent of the world’s population (WHO 2022). There is clear evidence that people with disabilities experience stark inequities across the spectrum of development priorities, including with respect to poverty, health, education, and livelihoods (Cote and Banks 2025). As an example, people with disabilities experience barriers to accessing health care, including inaccessible health facilities, health workers with limited disability training, and high additional costs (Gréaux et al. 2023). These barriers contribute to worse health outcomes for people with disabilities, culminating in a 16.4-year difference in life expectancy in LMICs (Kuper et al. 2024).
There are also large gaps in employment; people with disabilities are half as likely to participate in employment or livelihoods activities (UN 2024), and even where people with disabilities do work, they typically earn 10–25 per cent less than people without disabilities in LMICs (Cote and Banks 2025). Children with disabilities are also left behind in education, such as being more likely to be out of school or have never attended, and have lower foundational numeracy and literary skills (UNICEF 2021).
Exclusion from employment and education and the extra costs incurred through living with a disability (e.g. cost of assistive devices or accessible transport) means that people with disabilities are also more likely to experience poverty (Banks, Kuper and Polack 2017; Mitra et al. 2017). Moreover, these extra costs are not considered in poverty measures, meaning that the true proportion of people with disabilities living in poverty is likely to be even higher (Mont et al. 2023). Exclusions in one domain influence exclusion in others – for instance, the health gap is partly due to poor social determinants of health (e.g. education, poverty, and livelihoods), and exclusion from school may have long-term health and employment consequences. These gaps across health, education, livelihoods, and poverty are consistently observed for people with disabilities but may be even greater for people who face intersectional barriers across gender, rurality, socioeconomic status, and impairment type (Cote and Banks 2025). As one example, evidence from Global Disability Inclusion Report: Accelerating Disability Inclusion in a Diverse and Changing World shows that women with disabilities are less likely to work, earn 5–6 per cent less, and have worse access to health care compared to men with disabilities (ibid.).
These inequities have enormous impacts in the lives of people with disabilities and their families. They are also a violation of their fundamental rights, as outlined in the UN Convention on the Rights of Persons with Disabilities (UN 2006). It will also be more challenging to reach global goals, such as the Sustainable Development Goals, if we continue to exclude such a large segment of the population (UN n.d.). Despite the clear need, development programmes rarely prioritise, or even make efforts to include, people with disabilities, thereby reinforcing these inequities. For instance, a recent analysis showed that only 0.4 per cent of development financing for health was ‘disabilityrelevant’ in 2022, even though people with disabilities make up 16 per cent of the global population and are more likely to experience health inequities (Missing Billion Initiative 2025).
A ‘twin-track’ approach is often advocated to achieve disabilityinclusive development, which includes an emphasis on ensuring that the mainstream programme is accessible for people with disabilities while also offering additional interventions to address particular needs. As an example, a twin-track approach in education could include ensuring that school buildings and toilets are physically accessible (mainstreaming), and also offering assistive products required to support learning (targeted).
In this article, we will describe PENDA, and reflect on some of the challenges and lessons learned in undertaking this ambitious programme, in the hope that this will inform future research efforts.
A clear case for investment in disability-inclusive development, based on rigorous evidence, is required by policymakers and programme managers to support the prioritisation of disability-targeted or inclusive programmes. This need is now even more pronounced, given the many competing priorities for development funding yet shrinking pool of funding available as key countries reduce their development budgets and move away from a focus on investments in diversity, equity, and inclusion-related activities. It is also important to identify the most promising interventions and programmes, given that the current approach to inclusion is often piecemeal and guided by the objectives and experience of individual non-governmental organisations (NGOs).
The gold standard in evidence is often considered to be impact evaluations, in particular RCTs as they measure the causal impact of programmes/policies on outcomes of interest and the magnitude of produced impacts. In an RCT, the investigators first select the intervention that they are interested in evaluating. Examples could include a livelihood training programme for people with disabilities, adaptations to make schools more accessible, or provision of assistive technology. A sample of people from the population of interest is then selected - for instance, people with disabilities living in a district in Malawi. The intervention under consideration is randomly offered to some people in the sample, but not to others. The entire group is followed up over time and the key outcome of interest, such as enrolment in school, level of poverty, or health status, is then measured in all of the participants, whether they received the intervention or not. The investigators compare the outcome in the group who received the intervention to those that did not to infer whether the intervention had a benefit.
There are some key characteristics of RCTs which make the findings credible and reliable:
RCTs therefore provide reliable and unbiased information on whether a programme or policy is effective and therefore might be suitable for prioritisation, scale-up, or adaptation elsewhere. Their value is strengthened if they are combined with process evaluations (described in more detail in Section 6), which help us understand the experience and needs of people with disabilities and programme implementers, implementation facilitators, and barriers and mechanisms of impact.
The evidence base on ‘what works’ to promote inclusion of people with disabilities in development programmes is currently poor. We undertook an EGM in 2020 to identify, map, and describe the existing evidence of effectiveness studies on what works to improve development outcomes for people with disabilities in LMICs (Saran et al. 2020). Specifically, the EGM identified available impact evaluations and systematic reviews assessing the effect of interventions for people with disabilities and their families/carers across five domains: health, education, livelihoods, social, and empowerment. Overall, the EGM identified relatively few studies: just 166, of which 59 were systematic reviews and 107 were impact evaluations (frequently not RCTs). Not only was the evidence base small but it heavily focused on interventions in the health domain which made up 118 of the 166 identified studies. Education was the next most heavily populated (40 studies), but very few studies were related to social or livelihood interventions, and virtually none to empowerment. Furthermore, over half of the impact evaluations came from upper-middle-income countries. A further EGM undertaken by UNICEF also noted clear evidence gaps on inclusive interventions for children with disabilities (Thota et al. 2022).
We explored the available evidence more deeply by undertaking Campbell Systematic Reviews on interventions to improve education, social inclusion, and livelihood outcomes, respectively, for people with disabilities (Hunt et al. 2022; Saran et al. 2023; Hunt et al. 2025). Not only were there few studies identified for the reviews but studies often had a high risk of bias, predominantly due to small study size, lack of randomisation, or masking. Moreover, the interventions often focused on offering targeted services for people with disabilities, rather than addressing the barriers to inclusion in mainstream services. For instance, most interventions included in the systematic review on education targeted individual children with disabilities in an attempt to improve their functioning, skills, and competencies but did not focus on mainstreaming these children into the school by system‑level or school-level changes.
Nevertheless, the three systematic reviews showed promising results that interventions could work to improve outcomes for people with disabilities in LMICs. Limited evidence is available from high-income settings, and the relevance to LMICs is unclear (Clayton et al. 2011; McHale et al. 2020). There is therefore a clear need for high-quality impact evaluations to assess whether holistic approaches to disability-inclusive development improve the inclusion of people with disabilities in key areas of society.
The EGM and Campbell reviews showed that most of the available impact evaluations were of interventions focused on changing the person with disabilities rather than tackling societal barriers (Saran et al. 2020; Hunt et al. 2022; Saran et al. 2023; Hunt et al. 2025). We therefore had a clear priority to undertake studies of interventions addressing more systemic change, and measuring outcomes in terms of participation for people with disabilities. We aimed to select a range of interventions to evaluate, concentrating on different domains and varying mechanisms of action (see Table 1). Moreover, we focused on complex interventions including different components since there is no single ‘magic bullet’ that will work to close inequities experienced by people with disabilities. The EGM and reviews showed that there is particularly little evidence around the effectiveness of interventions in the livelihood and education domains. We also aimed to include diversity in terms of the profile of the participants targeted (e.g. impairment type, age) and country settings.
PENDA funding is for the evaluation of interventions, not their implementation. It was therefore necessary to coordinate with implementing partners to identify projects to evaluate. In particular, PENDA partners with the Disability Inclusive Development Inclusive Futures programme, composed of a consortium of NGO and Organisations of Persons with Disabilities (OPD) partners, led by Sightsavers and the International Disability Alliance (IDA), and funded by FCDO. Consequently, five of the PENDA evaluations focused on Inclusive Futures projects: (1) Star+, Bangladesh (Banks et al. 2022); (2) the Disability-Inclusive Ultra- Poor Graduation programme (DIUPG), Uganda (Kipchumba et al. 2024); (3) Inclusive Family Planning (IFPLAN), Nigeria (Marks et al. 2024); (4) the InBusiness programme, Kenya (Banks et al. 2023); and (5) the Shikhbo Shobai education programme, Bangladesh. The remaining interventions for impact evaluation were identified through a combination of outreach to partners (e.g. BRAC and the DIUPG in Bangladesh, UNICEF and the cash-plus programme in Lao PDR, and disability identification in Sierra Leone) (Banks et al. 2024), embedding disability within ongoing trials (e.g. ICC-T trial in Tanzania) (Mattonet et al. 2024), and raising funds for intervention implementation (e.g. PLA-D in Uganda, PDC/Baby Ubuntu in Rwanda).
The advantage of this approach is that there was an independent consortium evaluating the interventions, which gives more credence to the findings. However, it involved long‑term and close collaboration between the implementers and the evaluation teams, and coordination of multiple activities in different countries. At times, the implementation approach had to be adjusted (e.g. implementing only to those randomised to the intervention group) or the timelines adapted to allow ethical approvals and permissions to be obtained, which required strong buy-in from the implementing partner.
A major challenge was selecting interventions that were evaluable through impact evaluation, meaning the potential for an intervention and control arm and assessment before and after the implementation. It was also not possible to evaluate all components of implemented interventions. For instance, in the study in Nigeria that aimed to improve family planning coverage for women with disabilities, a component of the intervention was raising awareness through the development of a relevant storyline in a radio drama (Marks et al. 2024). However, the radio programme was transmitted across the region, and so it was not possible to identify an intervention and control group and therefore assess the impact it had on changing attitudes and awareness.
Within PENDA, impact evaluations are conducted predominantly through the gold standard approach of RCTs. There are, of course, concerns about RCTs. In particular, the question of whether it is ethical to withhold an intervention which may be effective from one group. RCTs are therefore often restricted to situations where there is genuine uncertainty as to whether the potential benefits of the intervention (e.g. a new drug) outweigh the potential harms (e.g. damaging side effects). For instance, in the DIUPG trials a valuable asset (e.g. a sewing machine) is given to a participant, and this may make them vulnerable to jealousy, theft, and violence (Kipchumba et al. 2024; Mugeere, Shakespeare and Carew 2024). Moreover, participants may be required to invest their own money through savings and loan schemes, which may then be lost through theft, mismanagement, or failure of the investment. The potential risks are therefore outweighed by the benefits, making it ethically appropriate to undertake the trial.
In many situations, the argument for an RCT can be made pragmatically as there may be limited funding to offer the intervention and so randomisation may be the most ethical way to decide where it is delivered. For several of the Inclusive Futures projects, for instance, there were a limited pool of people to whom the intervention could be offered which was far smaller than the eligible population. Randomisation to select who is allocated to the intervention is arguably fairer, and therefore more ethical, than selecting some areas out of convenience. It was not always possible to conduct RCTs. In Lao PDR, we were evaluating the impact of a government cash-plus programme for the families of children with disabilities which was offered to some pre-selected districts and not others. We therefore had to use a different form of impact evaluation – in this case a non‑randomised comparison study. However, we worked to avoid these alternative designs as far as possible, as the quality of this evidence is often considered to be inferior to evidence derived from an RCT as there are more potential sources of bias.
Another important way in which we worked to maximise the quality of the evaluations was by recruiting large sample sizes in all of the trials to ensure that they were sufficiently powered to detect meaningful differences between the intervention and control group. It is often still not possible, however, to allow disaggregated analyses by other intersectional variables (e.g. gender and impairment type), as the groups will become too small to allow a difference to be detected. It is also challenging to achieve sufficient sample sizes for all target groups. For instance, the Inclusive Futures programme has included several interventions aimed at people with deafblindness, but these could not easily be evaluated using RCTs due to the small numbers recruited. Methodological improvements were also made to improve the quality of data collection, such as guidance for measuring and addressing the extra costs of disability which was developed jointly by PENDA, the World Bank, UNICEF, and the Center for Inclusive Policy (World Bank 2025).
PENDA impact evaluations are each complemented by a mixed‑method process evaluation. While impact evaluations focus on identifying whether an intervention is effective, process evaluation focuses on identifying why and how they are effective. This focus is important because interventions do not take place in a vacuum but are deeply embedded within the contexts they operate in. PENDA’s evaluations cover 13 countries, which naturally differ in terms of factors such as their laws and policies, cultural norms, and systems and infrastructure. Additionally, some of the interventions that PENDA evaluated took place amid significant influential macro-level events (e.g. the Covid-19 pandemic). The interventions themselves are typically complex with several components designed to operate at different levels and among different groups. All of these factors make it difficult to determine whether an intervention found to be effective in one context and over one time period will be equally effective if implemented again in the future.
The integration of both impact and process evaluations by PENDA produces ‘learning for next time’, generating evidence on which interventions should be prioritised, and how they can be adapted and delivered effectively in new contexts (Kuper et al. 2020). To achieve this learning, PENDA process evaluations typically examine what happens during an intervention (e.g. how intervention components were delivered by implementers and received by participants) and identify why the intervention did or did not produce its intended effects (e.g. by identifying intermediate mechanisms that contributed to outcomes or unintended consequences that hindered them).
PENDA process evaluations also investigate the specific context in which an intervention takes place and how this has influenced intervention delivery and outcomes. For instance, the DIUPG trial in Uganda indicated a significant impact in terms of reduced poverty and improved health (Chen et al. 2025a, 2025b). The process evaluation highlighted the importance of social empowerment and improved societal attitudes to achieve these outcomes, but also the challenges to implementation associated with the pandemic such as the ability to provide rehabilitation and assistive technology (Mugeere et al. 2024). Theoretically, the view taken of evaluations in PENDA is aligned to a realist perspective, which emphasises the contextually contingent nature of interventions and the mechanisms and outcomes they produce (Pawson and Tilley 1997). Ideally, we would include economic evaluation within all evaluations, but this was only possible for a select number of trials due to limited capacity.
‘Nothing about us, without us’ is a foundational call within the disability movement, which we have tried to achieve within PENDA. Moreover, our belief is that inclusive evaluations will be of higher quality, as they are informed by the experiences of people with disabilities, and therefore produce findings that are more likely to have long-term impact. Consequently, we have made concerted efforts to include people with disabilities as researchers, advisers, and study participants.
A core challenge is the many systemic and life-long barriers to education and career progression that people with disabilities experience, meaning that there is a relatively small pool of trained people with disabilities to be engaged in research. We have therefore established a PhD scheme for people with disabilities as part of PENDA, through which we have trained three people, and this pilot has stimulated the expansion of this programme within LSHTM. We have also funded a work experience programme for researchers with disabilities, both at LSHTM and in Uganda, and undertaken OPD capacity development workshops in a range of countries.
At the same time, the call for ‘decolonising global health’ has led us to think carefully about how to create respectful and meaningful partnerships with academics from LMICs. There is no single ‘magic bullet’, and so we have put in place a number of strategies, establishing joint LSHTM and LMIC partner leads for each evaluation, including commissioning out two of the evaluations to be led by LMIC partners, supporting a range of capacity development efforts in LMICs (e.g. paper-writing workshops and in-country conferences), and aiming for fairly shared authorship in all publications. We have also developed a freely available online course, ‘Global Disability: Research and Evidence’, to which over 3,000 people have already enrolled.
PENDA included 13 evaluations in 13 countries, requiring a lot of coordination with a wide number of partners. Strong buy-in from implementing partners was needed to adapt their programme plans to allow the impact evaluation to be conducted. At times, there were also worries with the evaluation being seen as an external judgement, and so ongoing discussions had to be held with implementing partners. Academic partners are variable in their experience of disability research and infrastructural support, and this has also presented a challenge in some settings. However, we have seen strong interest and willingness to engage from partners, both already working on disability and new to disability programming. There is also a growing capacity of research around disability, with more institutions, trained researchers with disabilities, and funding available around the world.
The emerging evidence from the trials is also showing the strong potential for disability-inclusive development. For instance, the DIUPG implemented in Uganda shows that the intervention worked to improve livelihood inclusion and reduce some poverty outcomes, and improve access to health care (Chen et al. 2025a, 2025b). These positive findings led to BRAC implementing the programme in Bangladesh, which has allowed a second impact evaluation of the programme in a different setting. PENDA has also stimulated and contributed to other evidence-generation efforts. As an example, learnings from PENDA featured highly in the recently published Global Disability Inclusion Report, of which one of the PENDA team was the co‑editor and others contributing authors (Cote and Banks 2025). PENDA helped establish the Disability Evidence Portal,14 which was then taken over by Stellenbosch University, South Africa. The two Principal Investigators of PENDA, Tom Shakespeare and Hannah Kuper, are also now co-chairing the first ‘Lancet Commission on Disability and Health’, which will consolidate and generate evidence on this topic (Kuper et al. 2025).
There is a clear need for more high-quality impact evaluations to assess the effectiveness of disability-inclusive development programmes. Advancing this research agenda is complex – and depends on the availability of funding, strong collaboration between researchers and implementers, and a trained pool of LMIC researchers on disability including researchers with disabilities. PENDA has contributed towards addressing these gaps, but we call on other researchers, funders, and implementers to continue this work so that we can generate actionable evidence to help ensure that we leave no one behind in reaching development goals.
1 This issue of the IDS Bulletin was supported by UK aid under its flagship Disability Inclusive Development (DID) programme. The DID programme was delivered through two separate programmes. The eight-year consortium intervention, Disability Inclusive Development Inclusive Futures (Inclusive Futures) programme, led by Sightsavers and the International Disability Alliance, ran from August 2018 to March 2026. It has reached more than 19 million people and generated almost 300 learning and evidence resources to inform policy and practice on disability-inclusive development. The evaluation programme, the Programme for Evidence to Inform Disability Action (PENDA), was delivered by the London School of Hygiene & Tropical Medicine. The opinions expressed are the authors’ own and do not reflect the views of the funders.
2 Hannah Kuper, Professor.
3 Lena Morgon Banks, Associate Professor.
4 Mark T. Carew, Assistant Professor.
5 Emily Eldred, Research Fellow.
6 Georgina Gaskell, Programme Manager.
7 Islay Mactaggart, Associate Professor.
8 Sarah Marks, Research Fellow.
9 Sara Rotenberg, Assistant Professor.
10 Nathaniel Scherer, Assistant Professor.
11 Tom Shakespeare, Professor.
12 All of the authors are from the International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, UK. Hannah Kuper is the lead author. The other authors are members of the Programme for Evidence to Inform Disability Action (PENDA) management team, all of whom contributed equally and are listed alphabetically.
13 We acknowledge and appreciate the wide-ranging efforts, expertise, and influence of the many partners with whom we collaborate, and who lead various aspects of the programme. We are also grateful to the contribution of the former staff members of the PENDA management group.
14 Disability Evidence Portal: www.disabilityevidence.org.
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© 2026 The Authors. IDS Bulletin © Institute of Development Studies | DOI: 10.19088/1968-2026.163 This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International licence (CC BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original authors and source are credited and any modifications or adaptations are indicated.
The IDS Bulletin is published by Institute of Development Studies, Library Road, Brighton, BN1 9RE, UK. This article is part of IDS Bulletin Vol. 57 No. 1 March 2026 ‘Building Disability-Inclusive Futures’; the Introduction is also recommended reading.