Chapter 45 Wheelchair prescription in international settings
More than 20 million people worldwide are in desperate need of a wheelchair. Millions more require other mobility aids. The adverse effects of this basic lack of mobility are exaggerated by the fact that the majority of people with mobility disabilities in low-income countries come from the poorest sections of the community. Poor people with disabilities are caught in a vicious cycle of poverty and disability, each being both a cause and a consequence of the other.
Disabled people in low-income countries are disenfranchised, marginalized, and generally devoid of access to their most basic human rights. It is important to recognize that an appropriate wheelchair is merely a tool that provides people with mobility impairments greater opportunity to access their rights to an integrated lifestyle within their own communities, leading to greater independence and an improved quality of life.
Many donors of wheelchairs operate under a charity model rather than an independent living model. Wheelchair users in low-income countries often cannot afford to pay for their own wheelchairs, so government agencies, development organizations, and charitable and religious institutions act as consumers instead. The usual market forces of consumer-based supply and demand are absent; as a result, end users are removed from the design, production, and selection processes and become passive recipients of charity rather than empowered consumers. When donors focus their attention on the product instead of the end users, the distribution of wheelchairs takes precedence over the socioeconomic integration of people with disabilities into their communities.
The medical model defines mobility disability as a matter of impairment to be solved with wheelchairs. This common perspective of donors is flawed because disability is a problem of socioeconomic immobility as much as physical immobility. The issue is not simply that millions of people are physically immobilized, but that their immobility often prevents them from pursuing an education, marrying, having families, working to support themselves or their families, or otherwise participating in their communities. The social model advocates that disability must be seen as an ongoing part of life within local social, cultural, economic, and political contexts, and not as a medical emergency to be solved if only enough wheelchairs can be charitably given away to those in need. The technology is only part of the solution.
Wheelchair provision in low-income countries often is based on industrialized countries’ service models, which are inappropriate and ineffective. Infrastructure systems, such as health professionals and commercial wheelchair manufacturers, are lacking, and the largely rural population in low-income countries is not served effectively by an institutional-type health service. As a result, many wheelchair users do not have access to official health care systems (Table 45-1).
|Service Models||Industrialized Country||Low-Income Country|
|Beneficiary||Wheelchair user||Wheelchair user|
|Service||Few integrated services or professionally trained staff|
|Product||Commercial wheelchair manufacturer||Local workshop or donated wheelchairs|
Four types of wheelchair provisions are discussed. The strengths and weaknesses of each approach are assessed, with consideration of the issues involved in providing wheelchairs to low-income countries.
Many organizations, particularly in higher-income countries, have responded to the critical need for wheelchair distribution in low-income countries by refurbishing orthopedic hospital-style wheelchairs and delivering them overseas (Table 45-2).
|Recycled||Discarded wheelchairs fit in the “anything is better than nothing” approach|
|Low cost||Recycled and refurbished fairly inexpensively (through volunteer programs)|
|Fast||Large quantities can be delivered quickly|
Wheelchair designs from industrialized countries, designed for use in hospital or indoor settings, are not suitable for uneven or unpaved roads and sandy terrain
Large influx of free donated wheelchairs can put local wheelchair producers out of business, eliminating the long-term source of wheelchairs for the community
There are advantages to utilizing mass production and export of free wheelchairs if wheelchair designs and methods of distribution are carefully considered (Table 45-3). In the past, the process has been unsuccessful because of poor wheelchair designs and little consideration to the distribution system and the needs of the users.
|Appropriate||Designs are sometimes appropriate|
|Low cost||Mass production helps to lower the price of wheelchairs|
|Large quantities||Large quantities can be delivered quickly|
|Suitability||Designs that are not appropriate often will not be suitable|
|Durability||Repairs are difficult because replacement parts usually are not available locally|
Local workshops in low-income countries have been providing a service to wheelchair users for many years (Table 45-4). They often are established by disabled persons organizations (DPOs) that have been frustrated by the lack of appropriate wheelchairs in their own communities.
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