Increasing access to prosthetic services to address the unmet need of users in LMICs will require a multi-faceted approach that leads to long-term, sustainable access. Interventions that address global barriers to market access, encourage political prioritisation to increase prosthetic service capacity, accelerate the scale-up of innovative fitting technologies, and ensure local availability of affordable high-quality components are foundational to market access. This section proposes five strategic objectives and long-term desired outcomes that will build and strengthen the market for prosthetics services.
Data
Lack of data in LMICs hinders understanding how many amputees are (un)able to access prosthetic services.
Awareness and financing
Without such data, policymakers do not prioritise investments in expanding the sector.
Mechanisms for structured data collection – such as registries – have proven to positively impact investment and service delivery.
To initiate data collection, consensus on a core dataset of amputee/user data is needed.
Outcome measures and quantifying need can underpin the analysis of economic and health benefits for investing in prosthetic services.
Build consensus on outcome measures to underpin and standardise data collection and guide research in prosthetics.
Define the core data set useful to the industry, national, and international institutions to support policymaking and funding.
Design and implement mechanisms for data collection at global and country levels.
Develop the investment case – i.e. quantify economic returns to user, family, community, economy – for donors and LMIC governments to invest in prosthetics services.
Consensus on priority outcome measures and core data set.
Registry of amputees, adopted in LMICs, that is linked to a global platform.
An investment case which quantifies economic benefits of investing in prosthetic services.
Political prioritisation and long-term investments by policymakers and donors.
Political will and financing
Low political will from LMIC governments leads to a lack of investment and leadership in establishing prosthetic services.
There is limited reimbursement for users, who then have high OOP expenditures.
Provision
Prosthetic services require specialised human resources and infrastructure, both of which are costly to establish. LMICs have limited number of service units, largely in urban centres.
Users typically travel long distances, resulting in high indirect costs (i.e. travel, loss of income, accommodation, and caregiver costs).
Setting up a functioning prosthetic services system that is integrated with the healthcare and related service (i.e. wheelchair) systems will require significant investment in infrastructure and personnel.
Affordability is a barrier; users cannot access enough funds to cover all costs, including indirect costs.
Models of co-investments with the private sector are emerging, but require validation and support to achieve financial sustainability.
Support governments to develop a costed plan for prosthetic service expansion and coordinate funding with investments from different sources.
Support governments to simplify market entry requirements (i.e. registration, duties) for component suppliers and organise purchasing through local distributor channels.
Support LMICs to train, accredit, and hire prosthetists/orthotists to increase human resource capacity.
Pilot innovative models of user financing.
Validate and expand proven public-private partnership investment models for prosthetic services.
Increased capacity of accredited prosthetists/orthotists.
Costed national plans, supported with dedicated long-term funding for prosthetic services coordinated across various government and non-government sources. Policies that describe outreach, referral, financing, and decentralised prosthetic services at various levels of the health system including primary, community, and rural communities.
Clear market entry guidance for component suppliers.
Reduced customs, taxes, and duties on imported prosthetic equipment and components.
Increased coverage of prosthetic device use in countries with political will.
Improved availability of quality prosthetic services.
Affordable prosthetic component suppliers enter LMIC markets.
Research standards
No research standards to set minimum requirements for prosthetic research leads to poor set-up and execution of research, leading to inconclusive results.
Provision
Fitting innovations have the potential to decentralise certain aspects of provisioning, but have been not been scaled due to a lack of implementation, and economic and clinical evidence in LMICs.
Implementers lack clarity on technologies which could be deployed to strengthen service delivery models.
LMIC implementers need further clarity on whether innovative fitting technologies are suitable and cost-effective for their context, which requires further evidence gathering and expert consensus.
Current studies are not generalisable to other settings.
Define research standards to set minimum requirements and guidance for researchers and suppliers who conduct prosthetics research.
Close evidence gap and drive consensus on innovative fitting technologies that are ready to be scaled.
Support high-potential innovators to improve business models and operations to enter LMIC markets and achieve scale and financial sustainability.
For example, support validation in LMIC settings to increase availability of affordable silicone prosthetic liners.
Minimum standards for conducting research and implementation guidance.
New evidence on novel technologies.
Policy guidance or industry consensus issued on adoption of novel technologies.
Increased penetration of prosthetic liner use due to affordability, availability, and market validation.
Increased capacity to deliver services in LMIC settings with increased efficiency.
Supply landscape
LMIC markets have limited component options, due to lack of provider awareness of more affordable options and lack of incentives for those suppliers to invest in market entry.
Quality
Existing quality standards do not consider requirements for LMIC contexts, thus lack of transparency on the durability and acceptability limits uptake.
LMIC supply is largely limited to high-priced HIC suppliers or low-cost NGO options, which may not be suitable or affordable to all users.
Lower-cost components are available in global market but have little market penetration in most LMICs, because of lack of information on these product options for buyers and low market transparency on their quality and performance in LMIC context.
Increase market transparency of the global supplier landscape to buyers.
Drive transparency of quality of affordable components by developing a standard for evaluating suitability of components in LMIC settings.
Incentivise market entry of affordable high-quality component suppliers in LMICs through developing market tools and roadmaps, and providing catalytic procurement.
Improved guidance and clarity on product selection for clinicians, procurers, and users.
Increased availability of affordable high-quality prosthetic components in LMICs.
Empowered buyers can make comparisons across component suppliers to select products best suited to the needs of user and context.
Efficient supply channels
Prosthetics components are selected based on amputee assessment; thus local, responsive supply channels are needed to support providers.
Lack of flexible supply forces prosthetists and other buyers to procure ad-hoc from overseas suppliers, which can lead to delays in fitting and high costs to user.
Regional distributors have emerged that maintain component inventory and aggregate volumes across numerous buyers to achieve better pricing and responsive supply.
Strengthen regional distributors to access financing to expand capacity, improve service and product offerings, and reach more buyers.
Responsive supply channels that leverage effective regional or local distribution models.
Increased affordability of prosthetic services due to reduction in wait times, more efficient supply processes, and lower landed cost of components.
A competitive, healthy local market of an assortment of affordable prosthetic component options ready to meet the needs of all users.
This document was developed to support the identification of activities that will support increased and sustainable access to appropriate and affordable AT. As an overall investment and implementation strategy is developed, some of these proposed activities will be undertaken in the immediate term by the AT2030 programme, which is funded by UK aid and led by the Global Disability Innovation Hub, to test what works to increase access to affordable AT. Others will be complementary early investments that ATscale will take on or will become foundational to ATscale’s long-term investment in the space.
As interventions are shown to be effective, the investment case outlining the magnitude and types of investment needed will be further refined and developed. It is expected that different large-scale investments and financial instruments will be needed to achieve long-term outcomes. For example, system-strengthening grants may be needed to support the integration into the health system, while match funding or co-investments may catalyse government procurement and investment. On the supply side, donor investment may be leveraged to de-risk private investment in cost-effective supply mechanisms.