To accelerate access to assistive technology (AT), it is critical to leverage the capabilities and resources of the public, private, and non-profit sectors to harness innovation and break down barriers to affordability and availability. Market-shaping interventions can play a role in enhancing market efficiencies, as well as coordinating and incentivising stakeholders involved in demand- and supply-side activities. This document will address the key barriers and opportunities to increase access to prosthetic services. Since there is a significant overlap in prosthetic and orthotic service delivery, access to orthotic services will also benefit from the proposed interventions.
Globally, an estimated 1.5 million people undergo amputations every year and need to access prosthetic services. The need is growing in low- and middle-income countries (LMICs). However, despite evidence that using a prosthesis can improve quality of life and reduce mortality for amputees, the World Health Organization (WHO) estimates that only 5-15% of amputees who need prosthetic devices in LMICs have access to them.
The market for prosthetic solutions in LMICs is small, because prostheses need to be fitted through a service delivery process that requires specialised infrastructure and personnel, both of which are in short supply in LMICs. Governments have historically not invested in this sector, because they lack data and awareness of the need and economic benefits. In the absence of government investments, non-governmental organisations (NGOs) have developed service capacities, largely in response to emergencies that sometimes operate in parallel to government systems. Without support from governments and donors to integrate provision and expand capacity, prostheses are not accessible to most people that need them. Innovative socket manufacturing technologies, including digital fabrication and direct-casted sockets, have the potential to increase access. However, consensus is needed within the sector on the readiness of these technologies to be deployed in LMIC markets.
A few companies supply most of the prosthetic components worldwide, and these are focused on high-income markets that can bear more expensive and technologically advanced solutions. Alternative suppliers offering affordable products are entering LMICs from emerging markets such as China, Turkey, and India. However, limited transparency on the quality and performance of these components in LMIC contexts inhibit their uptake. Additionally, prosthetic components should be available through a flexible and responsive supply chain, since component selection is made by prosthetists/orthotists based on assessments of users’ needs and use context. While components in high-income countries (HICs) are often ordered individually from the manufacturer, logistics challenges in LMICs may not allow such an approach. An opportunity exists to increase access to affordable, quality, and appropriate prosthetic components, but will require more transparency and a more responsive supply chain.
High prices and poor perception of value of prosthetic services in LMICs, combined with high indirect costs for users to travel, makes prosthetic services unaffordable to many of people who need them. Prosthetic services can be made more affordable by: 1) increasing the number of service units (in particular, by leveraging decentralised service models and the innovative technologies that enable them); 2) establishing reimbursement schemes that encapsulate all costs to the user; and 3) leveraging alternative forms of financing for both capacity-building and user financing.
An opportunity exists to transform access to prosthetic services and products in LMICs, but this will require a coordinated effort between: 1) governments to expand service capacity; 2) global stakeholders to provide guidance on products and technologies; 3) suppliers to expand market presence and offerings; and 4) donors to support these activities. To accelerate access to prosthetic services in LMICs, the following strategic objectives have been defined:
Strategic Objective 1: Develop foundational datasets to inform the investment case for prosthetic services and guide the development of standards.
Strategic Objective 2: Support countries to define appropriate policies and invest in the key requirements of a functioning prosthetic provisioning system.
Strategic Objective 3: Accelerate market validation and adoption of innovative technologies that can simplify, decentralise, and lower the cost of prosthetic service provision.
Strategic Objective 4: Accelerate the uptake of affordable, quality prosthetic components by increasing market transparency to empower buyers to make value-based purchasing decisions.
Strategic Objective 5: Strengthen regional supply mechanisms to increase affordability and availability of quality prosthetic components.
These strategic objectives are supplemented by initial activities to support access to affordable, high-quality, and appropriate prosthetic devices and services. ATscale, the Global Partnership for Assistive Technology, is currently in the process of developing a prioritisation process to inform which of the market-shaping activities proposed in this document will be incorporated into the Partnership’s action and investment plan in order to guide activities and investments in the short-term. While that is underway, some of these proposed activities will be undertaken in the immediate term by the AT2030 programme, funded by UK aid, in line with its aim to test what works to increase access to affordable and appropriate assistive technology.