A less-resourced setting (LRS) has been defined as a geographic area with limited financial, human, and infrastructure resources. These conditions are common in low-income and middleincome countries but can also exist in some high-income countries.¹ Assistive technologies, such as prosthetic devices to help individuals with disabilities attain mobility, achieve equal opportunities, enjoy human rights, and live with dignity, are limited in these settings.^{2,3,4,5,6,7,8,9,10}

The World Report on Disability from the World Health Organization (WHO) and the World Bank indicates that more than one billion individuals around the world live with disabilities.³ Conservative population-based estimates suggest that 0.5% of any population may benefit from prosthetic or orthotic services;^3,5,9,11 in Africa, Asia, and Latin America; this includes an estimated 30 million individuals.¹¹ In many LRSs, the prevalence of disabilities is reported as higher than in well-resourced settings^10,12 and is expected to increase.^3,5 Irrespective of the setting, individuals with disabilities are known to have poorer health outcomes, lower educational attainment, reduced social and economic participation, and higher overall rates of poverty than those without disabilities.³ Individuals from typical at-risk groups such as women, the elderly, those with limited education, and the unemployed also are considered to be at increased risk of disabilities.³ These trends suggest a cycle of exclusion and a profound effect on those with disabilities living in an LRS.¹⁰

Access to appropriate, affordable, sustainable prosthetic services is important in mitigating this effect and presents challenges in LRSs. Appropriate services require collaboration among a spectrum of key stakeholders, including governments, funding agents, educators, industry, private enterprise, service providers, and the users of prosthetic services. Additional requirements include addressing the shortfall of adequately trained professional workforce and access to appropriate technology.¹³

The service and delivery of prosthetic devices in LRSs is provided by a range of stakeholders, which varies from country to country. The individual responsibilities between stakeholders within each country are unique and depend on the resources and capacities of the contributors. Services from referral through follow-up are often in short supply. They are commonly centralized in large cities and are usually located at a substantial distance from many potential users.²

Three major institutional donors, Deutsche Gesellschaft für Internationale Zusammenarbeit GIZ (formerly GTZ), the United States Agency for International Development (USAID), and The Nippon Foundation, have provided substantial ongoing support to improve access to assistive technology and monitor and evaluate the effect of investment in prosthetic orthotic services. Their input has generated activity in education, technology transfer, and services.

An impact assessment in East Africa by USAID indicated that its grants had a positive effect on the establishment of
services, the appropriateness of service delivery, and on the lives of individuals with disabilities.¹⁴

In South East Asia, the effect of The Nippon Foundation’s long-term investment in establishing professional prosthetic orthotic education and services in six countries was found to have transformed the lives of users and their families, enabling greater independence, participation, and inclusion. The investment is a starting point for prosthetics and orthotics services and should improve its reach through development of better referral and increased awareness. Despite these investments, there persists a broad lack of understanding of the benefits and needs of assistive technologies; a failure of infrastructure to procure, produce, and maintain devices; and the absence of a properly trained workforce.⁶

In addition to major institutional donors, one of the most significant contributors to services, education, and technology in LRSs is the International Committee of the Red Cross (ICRC) through its Physical Rehabilitation Programme in low-income, conflict, or postconflict settings.

In 2020 alone the organization delivered 174,711 assistive devices; of those, 12.5% were prostheses representing the fitting of 21,874 services users.¹⁵

Many countries have an existing legislative framework related to disability and/or rehabilitation. As of 2018, 175 United Nations Member States have ratified the Convention on the Rights of Persons with Disabilities.¹⁶ However, systematic barriers exist in the implementation of laws, including a lack of strategic planning, health infrastructure, health information systems, and communication strategies. These barriers are further compounded by a lack of agencies responsible for administering, coordinating, and monitoring complex referral systems, as well as inadequate consultation with individuals with disabilities.³

The provision of assistive technology for mobility has often been a low priority for governments. In a global survey of 114 countries on the equalization of opportunities for individuals with disabilities, 50% had not passed relevant legislation, 48% had no policies related to providing assistive technology, and 36% had not allocated fiscal resources to develop and supply assistive devices.²

The United Nations Convention on the Rights of Persons with Disabilities has been an important step toward providing an accountability framework for governments. Articles 4, 20, and 26 of the Convention specifically require member states to ensure access to assistive technology that is provided by trained professionals.⁴

In recent years, advocating for and advancing access to appropriate, affordable services for all users of assistive technology including prostheses has risen in priority for the global community. In January 2018 the Seventy-First World Health Assembly adopted the resolution that sets a global mandate to improve access to assistive technology. This resolution obliges member states to include assistive technology in universal health coverage as an integral part of achieving the Sustainable Development Goals, reducing the burden of noncommunicable diseases, contributing to the WHO’s comprehensive mental health plan and in tackling the other major contributors to global burden of disease.¹⁷

The resolution has cemented the following actions:

To further support these aims, the WHO has developed tools to assess system-level capacity to deliver assistive technology; measure the need, demand, and barriers; and to measure the effect of assistive technology on individuals.²³

In 2006, key stakeholders from 35 organizations and agencies agreed to a common approach to improve access to good-quality services for individuals with disabilities. The Prosthetic Orthotic Programme Guide,⁵ which was endorsed by the International Society for Prosthetics and Orthotics (ISPO), provides support to international and local aid organizations involved in supporting the establishment and development of prosthetic and orthotic services in low-income settings. The guide recommends considering the following principles (among others): Ensure that the project has been proposed by or is supported by government; support the establishment of services that provide both prosthetic and orthotic devices; build local capacity in both technical and managerial aspects within the program; promote the ideal that services should be open for all; work closely with carefully selected local partners and owners of the service; build services on existing systems with respect to such considerations as staff compensation and the procurement of materials; carefully consider the selection of technology and components (ie, consider technology already in use in the country, realistic expectations for cost, availability, clinical capacity, and technical capacity); and promote continuous evidence-based research.⁵

These guiding principles are considered key to developing services that are cost effective and sustainable. These principles are echoed in a 2011 joint position paper published by WHO and USAID on the provision of mobility devices in LRSs and the WHO Standards for Prosthetic and Orthotic Services,¹³ which encourage a comprehensive approach to service delivery.²

The 2017 Standards for Prosthetics and Orthotics Services with accompanying implementation guidelines aim to assist member states in setting up, improving, or transforming the delivery of services.^13,24 Building on previous work the Standards urges member states to include prosthetic/orthotic services in universal healthcare as an important step in achieving the Sustainable Development Goals.¹³

Funding limitations persist as a challenge frequently encountered in LRSs,² where individuals with
disabilities reportedly pay for more than 50% of the cost of assistive technologies.²⁵ Because disability is bidirectionally linked to poverty,³ the challenge of funding prosthetic services should not be underestimated. Studies indicate that individuals with disabilities have higher costs of living, higher health care expenditures,^3,26 fewer assets, and worse living conditions.³ In low-income countries with a per capita income as low as $664 USD,²⁷ it would be reasonable to suggest that the cost of prosthetic devices may be unaffordable for most individuals with disabilities.

In 2014, WHO issued a concept note on its GATE initiative to increase access to assistive technology. This concept note stated that the assistive technology industry is essentially a monopoly; the cost of products is overly high and does not take advantage of economies of scale; and global issues exist regarding limited funding for development and production, weak or nonexistent procurement systems, the absence of safety measures, and inadequate servicing and user training in LRSs.⁶

In the USAID impact assessment of East Africa, researchers reported that in Tanzania, Kenya, and Uganda (the three target countries), constraints related to cost, supply chain, and limited availability of consumables had a substantial effect on services.¹⁴ These countries reported heavy reliance on international, nongovernmental, and/or charitable organizations to fund services, which, anecdotally, is also considered to be true in other LRSs.

It is important that funding agents understand the complexities of providing prosthetic and orthotic services. Appropriate, sustainable services are considered a long-term endeavor and may require input or support over many decades to achieve acceptable results. Short-term assistance for users of prosthetic and orthotic services may generate few or no lasting results. In short-term endeavors, after a device wears out, beneficiaries may consider themselves to be in a worse situation than before having the device. ISPO recommended that the long-term objectives be prioritized over the narrower goal of supporting a large number of individuals as quickly as possible.⁵

Training a professional workforce is important for the delivery of appropriate services.^{2,3,4,11,14,28} The lack of professionally trained personnel is a barrier to providing appropriate services. Similarly, continuing education for existing personnel is insufficient.² In the 2005 United Nations survey on equalization opportunities for individuals with disabilities, 37 countries reported that no action had been taken to train personnel in rehabilitation, and 56% reported that the medical knowledge of health care clinicians related to disability had not been updated.²