Timeframe: September 2023 to February 2025

The challenge

Globally, approximately 90% of all vision impairment can be prevented or treated. Uncorrected refractive problems account for more than 53% of all cases of vision impairment.

In many low-and middle-income countries (LMICs), only a small part of the population is ever screened for refractive error so most people who need corrective lenses or other services are not identified. The existing refraction services often rely on highly qualified eyecare professionals (ophthalmic technicians, optometrists or ophthalmologists) of which there are few, and diagnostic services have a limited geographical reach. To partially address the shortage of eye care professionals, non-eye care specialists like community health workers are trained to provide screening services. 

Autorefractors are automated machines used to calculate the refractive error by detecting how the patient’s eye influences infrared radiation sent into the eye. Up until recently, this diagnostic technology has been too costly for many contexts. New innovations that are reasonably priced and simpler to use are now entering the marketplace and require testing to ensure effectiveness, safety and feasibility of scaling within LMICs to see whether and how autorefractors can become more commonly used to diagnose refractive errors. 

The intervention

Simple-to-use and affordable hand-held autorefractors have the potential to address challenges in addressing refractive errors, particularly for underserved populations that have little to no access to eye care. 

ATscale is supporting a large-scale study to determine the effectiveness and feasibility of using hand-held autorefractors in LMICs. This study will be conducted by IQVIA – a leading global provider of advanced analytics, technology solutions and clinical research services to the life sciences industry dedicated to delivering actionable insights in collaboration with L V Prasad Eye Institute – a World Health Organization Collaborating Centre for Prevention of Blindness, and the work will also be guided by global experts in the eye care sector. 

The study will compare the effectiveness (sensitivity and specificity) of different hand-held autorefractor models with other refraction devices (desktop and retinoscopy), determine the feasibility of prescribing eyeglasses based on results of autorefraction alone, and assess the potential for scaling up handheld autorefractors in public health settings within LMICs. 

The study will take place in Nigeria, Ethiopia and Nepal and will also evaluate how to best train community health care workers to use the selected autorefractors within different settings and for different populations – adults and children.

“The global incidence of near or distance vision impairment is at least 2.2 billion people where 1 billion people have avoidable vision impairment due to various causes. Nearly 88.4 million vision impairments are caused due to refractive errors which may be addressed by undertaking a population centered approach by bringing diagnostics and interventions at the doorstep of the community. We believe that the proposed study can support in mitigating the challenges posed by blindness due to uncorrected refractive errors by bridging the gaps in access to diagnostics and facilitating intervention measures.” – Dr. Santosh Moses, Principal Investigator

Timeframe: June 2022 to May 2023

The challenge

Globally at least 1 billion people have a vision impairment that is uncorrected or could have been prevented. Refractive error is the most common cause of vision impairment. Numbers will continue to increase due to population growth, aging, and lifestyle changes.

Several screening and eye care programs are currently being implemented globally. The outcomes vary depending on the country’s capacity, the screening process, the screening device, target beneficiaries and scale of end-to-end eye care. In LMICs, the suboptimal quality of screening interventions is an ongoing challenge. Additionally, anecdotal evidence suggests huge gaps in end to end post-screening service delivery models. It is important to provide technical guidance to the countries to address quality challenges in screening and ensure provision of eyeglasses as a part of the interventions.

The intervention

ATscale supports WHO in its development of a handbook to provide technical guidance for developing and implementing early vision screening and end to end provision of eye care, with increased attention to the correction of refractive error using eyeglasses. It will cover important factors such as screening targets, screening site, evidence based screening tests and innovative devices, referral criteria, human resource requirements, and various service delivery models on integrating screening with eyeglass provision for school and non-school school going children and older adults.

The result

A technical guidance document to help countries in the provision of quality eye screening, referral and provision of eyeglasses.

Read the Vision and eye screening implementation handbook

Timeframe: June 2022 to Dec 2022

The challenge

The World Health Organization (WHO) estimates that unaddressed hearing and vision impairment poses an annual global cost of US$750 billion and US$ 270 billion respectively with negative impacts on education, social life and employability of those affected. 

It is critical to identify hearing needs as early as possible in childhood, which is also the case for vision. For several reasons, i.e. highest burden in the similar age group, potential to identify both the conditions together in community settings, and possibilities of skill transfer to primary healthcare workforce etc., it has increasingly been felt by experts that the hearing and vision screening interventions can potentially be combined. Some countries have been implementing such integrated models but not much is known about them. To bridge this knowledge gap, it is important that such models are studied with rigorous scientific methodology and explore the potential for scaling up such interventions sustainably in LMICs. 

The intervention

Whilst the body of evidence grows further around this, work needs to be pursued to develop initial learning and/or guidance as a background paper on combining vision and hearing screening (for groups such as school children and the elderly), based on experience so far in several countries. ATscale supports WHO to conduct a scoping review of literature, stakeholder consultations to identify effective models and discuss the implementation and production of a background document including (not exclusive) rationale, benefits, challenges, limitations of different models and recommendations. 

The expected result

A background paper setting out the possibilities of combining hearing and vision screening for the targeted population including a set of recommendations.

Timeframe: June 2022 to Dec 2022

The challenge

WHO estimates that 72 million people worldwide need hearing aids, but only 10% that need at least one have them overall, with coverage less than 3% in low- and middle-income countries (LMICs). Experts recommend that hearing aids be delivered in the context of an Ear and Hearing Care (EHC) programme within the health system, Despite the availability of Assistive Product Specifications (APS), access to affordable and quality hearing aid products is difficult to achieve. Limited suppliers, information asymmetry, weak procurement capacities coupled with absence of universally accepted quality standards often lead to the limited access to quality hearing aid products.

The intervention

Improving access to hearing care, including high-quality, affordable hearing aids, is a critical step in mitigating the adverse impact of hearing loss. Existing APS provide a certain level of clarity on quality to procurers but they don’t serve as an established quality standard since hearing aid quality measures go beyond the specifications. Additionally, for a number of reasons, countries might not be interested in purchasing hearing aids from the manufacturer selected through pooled procurement mechanisms guided by APS. Prequalification (PQ) of hearing aids could be a step in the right direction. Developing a business case will help determine the merits (or not) of establishing a PQ mechanism for hearing aids. To this end, ATscale supports WHO to undertake a detailed desk review and expert consultation with manufacturers, procuring agencies, and users to build a business case for pre-qualification. 

The expected result

A business case for hearing aids will describe the market landscape, the need, access, barriers, key stakeholders, the role of PQ, economic viability assessment and a set of recommendations.

Timeframe: December 2021 - August 2022

The challenge

The cost of quality products and services is one of the major barriers to accessing lifesaving assistive technology (AT) in low-and middle-income countries (LMICs). Lower-cost suppliers exist, but those responsible for procurement in LMICs often have little visibility of who they are, what they offer and of what quality. Suppliers, on the other hand, lack understanding of the demand, which prevents them from entering LMIC markets. In many global health markets, market intelligence interventions are supporting better functioning markets, e.g. for products to treat or prevent HIV and malaria. Better market intelligence and visibility is needed in the AT sector to support access to appropriate assistive products at more affordable prices.

The intervention

This project will build on the Product Narratives developed for AT2030 and ATscale and will map and prioritize market intelligence gaps in the AT sector – focussing on wheelchairs, prostheses, hearing aids and eyeglasses - and identify the most appropriate market intelligence interventions to benefit the AT sector. Recommendation will suggest where and how ATscale can potentially engage and add value.

Grantee: Clinton Health Access Initiative

Report: AT Market Intelligence Scoping Report “Strengthening Market Intelligence for Assistive Technology (AT)”

Policy choices by governments about how and when to introduce or scale up AT programmes and how to include them in public (health) systems and insurance schemes in lower- and middle-income countries should be informed by reliable estimates of the resources required to deliver assistive technology (AT). However, these are currently not available.

The aim of this intervention was to help close this gap by providing decision makers in ministries responsible for the provision of assistive technology with tools to support the generation of the cost-related data they need to inform their plans.  

Two different costing tools were developed - one that supports planning at a strategic level and one for the costing of concrete assistive product provision packages. They are excel-based AT costing models that allow for tailoring to take into account different scale-up strategies, models of provision and the inclusion of different assistive products (eyeglasses, hearing aids, wheelchairs, prostheses). The tools are versatile and adaptable to varied contexts.

AT National Policy, Strategy, Planning (NPSP) Costing Tool

The AT National Policy, Strategy, Planning (NPSP) Costing Tool calculates multi-year cost projections of the resources needed to implement strategic activities and inventions linked to a national AT policy, strategy, or plan and produces multi-year cost projections. It is designed for health planners and policymakers to help inform budget planning and financing dialogue.

The tool has already been used in Liberia, Malawi, and Sierra Leone to cost national AT plans.

The package includes:

• NPSP user guide

• NPSP blank tool

• NPSP tool populated with sample data

Assistive Product Provision (APP) Costing Tool

The Assistive Product Provision (APP) Costing Tool calculates costs for a five-year projection of start-up costs and incremental costs per person for assistive product provision packages. The tool can also model combined provision of these services (e.g., within school health or primary health care). The tool is designed for health system managers and policymakers to help plan future services and prepare investment cases.

The tool has been used in South Africa to cost comprehensive hearing services and will also be used to plan the cost of integrated vision/hearing service provision. 

The package includes:

• APP user guide

• APP blank tool

• APP tool populated with sample data

The issue

One of the major impediments to making the case to policy makers to support rehabilitation services for people with lower limb absence is the lack of standardised data to demonstrate impact. Impact can be demonstrated by collecting data on outcome measures which reflect changes in the functional level, health, and quality of life attributable to the prosthetic device. However, a lack of consensus on outcome measures has caused various interpretations and evaluations of existing solutions, both in terms of health outcomes and economic returns.

The intervention

The International Society for Prosthetics and Orthotics (ISPO) ran two international consensus processes. The first to establish a core data set for lower limp absence to ensure included data items are relevant, realistic and appropriate across the world with the aim of informing policy decisions and the set-up of local amputee registries to support rehabilitation programmes.

A second international international consensus process ensured standardised outcome measures for routine clinical practice which require few resources, a minimum of time, are appropriate in a wide variety of contexts and yield valuable information for people with lower limb absence, clinicians, managers and policy makers. These outcome measures will inform the investment case for prosthetic devices, as well as research protocols and standards for new technologies and solutions, and open opportunities for development and evaluation of new service delivery models.

The result

Lower Extremity Amputation Data Set (LEAD)

LEAD is a core data set of information that can be collected in a registry or database. Use of a core data set allows standardisation of data items across data collection efforts to facilitate comparison and aggregation of data to answer real world questions for users of rehabilitation services, clinicians, managers and policy makers. Details of a data dictionary to facilitate consistent data collection as well as other discussion of themes relevant to registry or database design and use can also be found in the project report.

Consensus Outcome Measures for Prosthetic and Amputation Services (COMPASS)

COMPASS is a list of standardised outcome measures for routine clinical practice. By collecting outcome measurement data before and after an intervention the effect of the rehabilitation interventions can be determined. 

COMPASS is supported by the COMPASS+ for high functioning individuals, the COMPASS Adjunct and a further recommendation about the collection of a health-related quality of life measure that is locally relevant. COMPASS is also included within LEAD to provide data about outcomes.

A COMPASS User Guide details protocols and supporting material to ensure that outcome measures contained in the COMPASS are administered in a standard way which is critical if the data is to be reliable for comparison and aggregation.

Read the Project Report

Read the COMPASS User Guide

The challenge

The majority of individuals with significant hearing loss live in low- and middle-income countries, yet only a small proportion of the hearing aids produced and fitted each year are delivered there. Hearing aids have been shown to reduce the impacts of hearing loss and increase the quality of life of recipients, but are typically expensive, and require fitting by a highly trained professional. Therefore the use of pre-programmed hearing devices, which can be delivered by minimally trained healthcare workers, is of particular interest as this service delivery model can potentially be used on a large scale to meet the enormous unmet need.

The intervention

This intervention brought together a Global Hearing Cooperative network from 23 sites in 16 countries managed by Macquarie University (Australia) who identified the hearing profiles and characteristics of clinical samples across a representative sample of low- and middle-income countries. In a second study, conventionally customized hearing aids and pre-programmable hearing aids were compared in a laboratory and clinical trial to better understand their potential benefits and limitations.

The results

Clinical populations in low- and middle-income countries reviewed differ from those in high-income regions in several important ways. There is a higher proportion of severe and profound hearing loss, and also of conductive and mixed hearing losses. The common patterns of hearing loss (hearing profiles) were flatter than those reported in studies from high-income regions.

Therefore, pre-programmable hearing aids should include settings/amplification profiles that reflect the (flatter) hearing profiles seen in low to middle-income countries.

In order to meet the needs of a wider range of the target population, a pre-programmable device with adequate power to fit up to a moderately severe hearing loss should be selected. Alternatively, both a lower power and a higher power device should be utilized.

Objective measures of outcome showed that pre-programmable hearing aids were able to meet an adequacy criterion for a limited number of clinical profiles. However, results were poorer and less consistent across profiles than with conventionally customizable hearing aids with only approximately 50% of participants obtaining an adequate fitting. Despite this, the subjective outcomes of pre-programmable hearing aids were on par with those of conventionally customized hearing aids.

• Pre-programmable hearing aid programs should target individuals with mild to moderately severe hearing loss.

• Triage of those with more severe to profound hearing loss to a more conventional fitting, or to manual communication programs should be considered.

• Pre-programable hearing aids are a highly scalable method, capable of supporting hearing rehabilitation for a significant proportion of the hearing impaired population in low- and middle-income countries.

Read the final report in

• English

• Arabic

• French

• Russian

• Spanish

The challenge

An estimated 65 million people live with limb amputations globally and most amputees need prosthetic care, yet the World Health Organization (WHO) estimates that less than 15% have access in low-and middle- income countries have access. Affordable, quality prosthetic components are critical for achieving optimal health outcomes. When conducting a sector analysis in 2019 on behalf of AT2030 and ATscale, CHAI found that informed purchasing of prosthetic components is complicated by three factors:

1. poor visibility on the existing suppliers; 

2. opaque quality markings, poor quality control and limited education among workforce on quality; and

3. no standardized approach and limited clinical field testing.

The intervention

A healthy market is a transparent market. When buyers know which suppliers exist and have optimal visibility on how prosthetic devices perform in laboratory and field testing, they can make informed purchase decisions. The project aimed to scope possible steps towards increased market transparency especially for prosthetic components.

The results

In partnership with industry experts, a prosthetic landscape study was conducted. 95 suppliers were identified of which 34 were shortlisted for an interview and 17 could be reached. Out of those interviewed, only a minority of companies reported to be selling in low- and middle income countries. This is informed by order volumes, ease/difficulty of product registration and ability to compete including regarding quality of products. Most suppliers reported to be ISO certified (82%), although one in four suppliers who indicated ISO certification did not indicate how they test for ISO compliance. In addition, 47% of suppliers indicated that they do not do field testing prior to introducing products to the market.

To create a healthier market, it is proposed to

1. enhancing transparency through a global supplier information-sharing system 

2. strengthen quality by supporting suppliers with laboratory testing, and 

3. standardizing the approach to field testing.

In parallel, country regulatory frameworks need to be strengthened and access partnerships with suppliers of quality products should be explored.

Moving forward

Strengthening market transparency is a critical step to enhance market dynamics and this project outlines ways to achieve this. No donor has yet invested in such initiatives and ATscale is uniquely positioned to support this work and actively stimulate market uptake of affordable, quality components. Partnering with a multidisciplinary organization(s) that represents a broad network of professionals involved with the delivery of prosthetics and orthotics could be considered.

The challenge

In order to meet the needs of people who use wheelchairs, wheelchair providers must have a range of adaptable products available. Numerous challenges (including high cost of logistics, long lead times, complex stock management, and insufficient quality) inhibit the availability of appropriate wheelchairs in low- and middle-income countries especially. One potential solution to overcome these challenges is a global procurement, consolidation and distribution platform. The Consolidating Logistics for Assistive Technology Supply & Provision (CLASP) project was set up by Momentum Wheels for Humanity with funding from USAID to ensure a flexible and cost-effective supply of quality wheelchairs.  

The intervention

Assessing the learnings from CLASP, this intervention carried out by the Clinton Health Access Initiative (CHAI) aimed to provide recommendations on how distribution platforms can improve the supply chain and market dynamics for wheelchairs to deliver even greater value to current and future wheelchair buyers across low- and middle-income countries. The project also investigated how economic sustainability can be achieved by learning from other distribution and procurement mechanisms in global health.

The Results

A comprehensive analysis indicated that a global order consolidation and distribution platform is valuable but can only be economically viable when it operates at a certain scale. A model such as CLASP could potentially be modified to meet this need along with continued investments to stimulate or activate public sector purchasing of appropriate wheelchairs.

CLASP will provide lessons as the basis for redesigning this mechanism. CHAI proposes that in a possible future redesign, the programmatic elements with the highest impact, which facilitate access to appropriate, quality products, should be maintained. These include: 1) quality-assurance; 2) a large selection of products - one stop shop; 3) flexible ordering; 4) technical support to buyers; and 5) a social mission which translates into competitive margins.

To attract a broader range of buyers, the following initiatives should be introduced: 1) extended payment terms which are necessary to help buyers manage cash flows; 2) focused demand generation to ‘lock in’ high-value markets; and 3) expanded demand generation functions with greater in-country presence.

A future mechanism should restructure elements of CLASP for long-term sustainability and maximum impact. It will be important to establish a future mechanism as a standalone entity for various reasons, including greater independence. This standalone entity will then establish a financing facility (working capital). In the meantime, the current mechanism should rearrange the current logistics function and seek an expert partner in distribution in emerging markets thatcan expand market penetration at the lowest possible logistic costs.

Moving Forward

The United States Agency for International Development (USAID) is working with Momentum Wheels for Humanity to implement the findings of the report. An extension of CLASP through August 2023 was designed to support CLASP to implement the recommendations.

Banner photo: Deafkidz International