Wheelchair provision in low-income countries

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.

Financing of mobility aids

Why the independent living model should replace the charity model

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.

Why the social model should replace the medical model

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.

Why appropriate service models should replace the industrialized health service model

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).

Table 45-1 Comparison of industrialized and low-income countries service model

Service Models	Industrialized Country	Low-Income Country
Beneficiary	Wheelchair user	Wheelchair user
Service	Occupational therapist Physiotherapist Rehabilitation engineer Clinical assistant	Few integrated services or professionally trained staff
Product	Commercial wheelchair manufacturer	Local workshop or donated wheelchairs

Evaluation of wheelchair provision approaches

In order to provide comprehensive responsible service and appropriate long-lasting wheelchairs, the approach to provision must meet the following four criteria:

1. Adjustability: The wheelchair must be made to the measurements of the user or easily adjustable to fit the user. It must always come with a pressure relief cushion that can be maintained or replaced.

2. Suitability: The wheelchair design must reflect the terrain that the wheelchair user will push through. Wheelchairs must be available in a range of designs that will meet individual needs and ensure quality of life and independence.

3. Durability: The wheelchair must be well made, durable, and easily repaired. Replacement parts should be easily available.

4. Sustainability: The wheelchair should be supplied in a manner that provides wheelchairs to the community for the long term.

Wheelchair distribution methods

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.

Donation of recycled wheelchairs from industrialized 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).

Table 45-2 Donation of recycled wheelchairs approach

Strengths
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
Weaknesses
Adjustability	Rarely adjustable to fit the individual Often incorrect size for children High risk of secondary complications due to poor fit
Suitability	Wheelchair designs from industrialized countries, designed for use in hospital or indoor settings, are not suitable for uneven or unpaved roads and sandy terrain No choice in wheelchair design for individual needs
Durability	Wheelchairs are unsuitable for harsh conditions and break easily Repairs are extremely expensive or not possible when replacement parts are not available locally
Sustainability	Working with a “charity” model approach Large influx of free donated wheelchairs can put local wheelchair producers out of business, eliminating the long-term source of wheelchairs for the community No follow-up or support for wheelchair users after distribution Health authorities do not take responsibility or make provisions for wheelchair services

Mass production and export of free wheelchairs to low-income countries

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.

Table 45-3 Mass production and export of free wheelchairs approach

Strengths
Appropriate	Designs are sometimes appropriate
Low cost	Mass production helps to lower the price of wheelchairs
Large quantities	Large quantities can be delivered quickly
Weaknesses
Adjustability	Wheelchairs are often not prescribed Expatriate staff are not based locally in the country and therefore are not available for review or follow-up (if wheelchairs are prescribed)
Suitability	Designs that are not appropriate often will not be suitable
Durability	Repairs are difficult because replacement parts usually are not available locally
Sustainability	Working with a “charity’ model” approach Mass distribution of chairs is damaging to local producers “Ceremonies” that hand out wheelchairs free to users are demeaning and patronizing No follow-up or support for wheelchair users after distribution Health authorities do not take responsibility or make provisions for wheelchair services Considerable transportation costs used for this approach could have been spent on strengthening local production

Local workshops

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.

Table 45-4 Local workshops approach

Strengths
Adjustability	Individually fitted wheelchairs Can be custom built to suit a wider range of needs Follow-up service
Suitability	Needs of the individual are assessed to prescribe the most appropriate design < div class='tao-gold-member'> Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Related Related posts: Appropriate technologies for assistive devices in low-income countries Orthoses for the muscle disease patient Upper limb orthoses for the person with spinal cord injury Sports adaptations for the physically challenged athlete Orthoses for cerebral palsy Protective equipment to the upper limb in sport Stay updated, free articles. Join our Telegram channel Tags: AAOS Atlas of Orthoses and Assistive Devices Jul 12, 2016 \| Posted by admin in ORTHOPEDIC \| Comments Off on Wheelchair prescription in international settings Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access