On the Offer of Appareillage Services in Developing Countries

ON THE OFFER OF ASSISTIVE DEVICES SERVICES IN DEVELOPING COUNTRIES

Some points regarding the situation

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1. Situation of assistive devices within the framework of assistance to mine victims

Together with physiotherapy and psychological support, assistive devices are part of the physical rehabilitation process within the framework of assistance to people with disabilities.

Therefore it is one of the main components for assistance being provided to mine victims, as are pre-hospital and hospital care, physical rehabilitation, social and economic reintegration, laws and policies, as well as sanitary and social surveillance.

In all regions, rehabilitation services are rarely provided free of charge. Foreign NGOs are of great help to the extent that they allow mine victims to obtain prostheses at a very low price or even at no cost at all. In fact, government services often encounter problems to provide prostheses, which means that victims have to wait for a very long time or buy them at a very high price.

Psychological support, an important aspect of rehabilitation, is rarely offered. Nevertheless, improvements have been observed compared with the information gathered in 2000[1]. In a number of countries, rehabilitation services are mainly concentrated in the capital or in large urban areas, whereas the regions affected by mines and their victims are often located in remote areas. It should be noted that the rehabilitation services available in urban areas are, in general, of a better quality than those offered in rural locations. Such is the case in the Middle East, Africa and Latin America. Community based rehabilitation programmes (CBR) can partially solve this situation by providing assistance locally within the communities.

Assistive devices have been developed following two main lines of action: the production of prostheses to replace an amputated limb and the production of orthoses to support or correct an existing but deficient limb. There are also other components such as the production of orthopaedic shoes and technical aids walking or rolling (chairs, tricycles). Numerous other types of assistive devices are also manufactured to respond to a great diversity of pathologies.

Implementation of this assistance in the countries affected

The provision of assistive devices is implemented by medical and social institutions (public or private) in the affected countries, with help from international associations and organisations, as well as with the support of bilateral or multilateral co-operation.

International NGOs develop local capacity in co-operation with governments. The ultimate objective is to transfer handling to local actors, whether they are in government organisations or form part of associations.

2. Some general problems common to many countries

The level of services varies a great deal from country to country and from programme to programme. Some problems, however, are common to many countries.

2.1. Implementation of a scheme for distribution of prosthetic and orthotic services

Lack of data on people with disabilities

It is estimated that 0.5% of the population need prosthesis or orthopaedic devices. This estimate could be below the real figure, particularly in some regions where polio is still present[2].

This is also the case after a very intensive conflict resulting in a number of war traumas or when a conflict comes to an end, as a result of the presence of land mines. It can also occur after a natural disaster of great dimensions. In those instances, the number of people suffering amputations and in need of prosthesis increases considerably, compared to the average figure in a country that has not experienced this type of disasters.

In the year 2000, Africa, Asia and Latin America had a total population of some four billion people, of which twenty million needed orthopaedic devices.[3]

Lack of specialised services

In Africa, there is an average of two million people per unit of assistive devices production. By comparison, the average in the West would be two to four hundred thousand people per unit.

Many countries in Asia, particularly in the Southeast, as well as in South and Central America, have improved conditions, but are still closer to those in Africa than to those in western countries[4].

Production that does not respond to demand

The total number of assistive devices manufactured in developing countries only covers a maximum of 10% of the actual demand[5].

The most vulnerable people (people with disabilities, often lacking economic power) frequently do not know that such services are available, do not benefit from them and are thus prevented from leading active lives.

Centralisation of services

Services remain concentrated in large urban areas, making access difficult for the population in need as they learn about the availability of these services. In fact, the demographic density must also be taken into account. In areas where the population is distributed over a large territory, workshops must be set up in accessible locations and staffed with technically competent personnel.

All national plans for the distribution of prosthetic and orthotic services should begin by establishing said services in provinces (or regions). Countries already ensuring services at that level should contemplate their distribution at district level (or in rural areas). Distribution plans will vary from country to country, the size of the population and the data (existing and/or collected) on people with disabilities.

2.2Plan and contents of specialised training

Lack of trained personnel

A fair balance must be found between international training standards, the reality of each countries and the motivation of technicians to develop and manage peripheral services.

In the field of rehabilitation, technicians must be trained in their future professional tasks, the attitude to adopt in their relationship with patients, members of the clinical team and with other actors (such as an administration, a local association, colleagues, etc.). The technical aspects of their professional practice should not replace communication with the patient, and they should have the capacity to master basic knowledge, interpret new situations and propose innovative solutions.

Unsatisfactory quality of the assistive devices

If training programmes are not adapted to the country context, the assistive devices produced will not respond to the social and economic criteria of the population with disabilities.

The techniques should allow for the simultaneous combination of the economic dimension, the ease of implementation and the aesthetic aspect, permitting at the same time the local or regional production of necessary components, in close alliance with local associations and with operators that have the know-how. In addition, it is advisable that these choices be made in conjunction with the conventional technologies used in other more developed countries, so that local technicians and professionals join the world of orthoprosthetics.

Inappropriate technologies

The correct balance must be found for the use of local materials, imports from the sub-region or from the West, so as to propose a range of assistive devices that respond to the socio-economic criteria of the population being targeted.

The technology used in an emergency situation should not carry the risk of creating a technological impasse or a dependency, and should subsequently allow for a harmonious evolution towards different options. In this context, where it is important that the person not “remain” in his or her situation of disability, the priority is expedite production, regardless of price and aesthetics.

The system for the supply of parts has consequences for all aspects of the national services planning and training schemes. Certain countries depend on the industrialised nations, especially for the parts needed for prosthesis. In the majority of cases, the parts imported are expensive, the price of the devices is high and the distribution of services is inadequate. National plans for the supply of parts should be carefully prepared. Few countries have the necessary financial resources to use imported parts in the production of all the devices they require.

Non-priority services for governments and care systems

-Lack of national policies

-Lack of a strategic plan

-Lack of a central coordination structure

-Lack of integration at the level of the care system

-Lack of mobilisation of resources

Together with the training, work must be done on the recognition of rehabilitation professionals, as well as on the implementation of a national policy, a strategic plan and a central coordination structure.

Whatever the degree of government involvement, it must be mobilised at different levels, or define a clear strategy for delegating the various levels of intervention: the State as provider of orthopaedic services and/or the State as regulatory entity and/or the State as the provider of finance.

The benefits to be channelled to people requiring assistive devices should not be limited to the supply of the device needed. They should also be taught to take care of their limbs, to prevent deformities and to use their device in a proper fashion.

Over the long term, the excessive exclusiveness of amputee care destabilises the basis for a coherent public health policy in favour of people with disabilities. Even when there are many amputees in a country, they are always a minority compared with other types of people with disabilities. The technologies chosen for the assistive devices of amputees must be coherent with those of other types of assistive devices and technical aids.

Orthotic Services neglected

Unfortunately, national and international support programmes have a tendency to focus their action on the assistive devices for amputees of the lower limbs, because they are in fact a new group constantly on the increase in countries at war or coming out of a war and with the presence of landmines, whereas the number of people with orthotic needs is always higher (lower limbs paralysed and deformed, club feet, scoliosis).

There is a tendency to forget that accidents caused by landmines can result in the need for orthotic devices and that the consequences of polio are on the increase in a country where the vaccination programme is barely carried out.

2.3.Capacity for administrative and financial management of services

Dependence on foreign support

The participation of ministries and local NGOs should be established from the beginning of the programme. Training should also be provided to local counterparts for the development of their service management capacities.

Experience shows, in fact, that if the interest of rich countries and donors concentrates on those countries in a situation of crisis, the international actors in the area should not lose sight of the fact that, prior to the crisis, those countries had their own development and modus operandi, to which they will return once the crisis is over. In the majority of countries where programmes exist, the orthopaedic projects implemented go on for at least ten years.

Assistive devices services in developing countries are generally the responsibility of the Ministry of Health or the Ministry for Social Action, local NGOs, private enterprises or a combination of the three.

The strategies to strengthen or develop local capacities vary a great deal from organisation to organisation, but their common objective is to go from an emergency situation to a development action, aiming at the sustainability of the services (technical, administrative and financial viability).

Limited financial means

The planning of the services to be introduced throughout the national territory must be done bearing in mind the cost of setting up the workshops. This will vary a great deal according to the materials used and the equipment needed for manufacturing the devices.

From that moment onwards, the cost of the devices will be taken into account. The mechanisms to pay for the devices are key in the implementation of a permanent strategy. This work is at least as important as the technological considerations.

3. Which way for the landmine victims assistance programmes?

A global approach

Rehabilitation and orthopaedic services form part of a global approach to assistance, which has a variety of objectives:

The reduction of risk factors that cause disability or aggravate vulnerability;
The development of aptitudes and autonomy in injured and disabled persons, and the realisation of their way of life and projects;
Adaptation of environmental, social or physical factors and, in that respect, adaptation of the services to the persons (individuals, families, groups, communities), as well as better access to what is available and to services; and
Development of social participation to reduce situations of handicap, vulnerability and exclusion.

Principles for action

Actions for assistance to victims should aim at rapidly improving the situation of people injured and with disabilities, as well as that of their families, prioritising the development of care provision and local services.

The sanitary, medical, social, technical and socio-economic measures proposed must follow the principle of non-discrimination between categories of victims and types of disability, the principle of precaution ("primum non nocere" – to not cause harm) and must contribute to respect for people’s dignity.

Assistance to mine victims should tackle both specific suffering and prejudices, and should be the result of a global approach to dealing with trauma and disability.

The actions proposed should be incorporated into the national policies for public health and social assistance, as well as into reconstruction and development efforts. They should be respectful of the existing institutional and sectoral frameworks and seek the sustainability of the process through the implementation of associations. Insofar as is possible, the actions will be based on techniques and technologies appropriate to the patients’ environment, and on the resources available at local or regional level. They will contribute to the reduction of the phenomena of substitution and dependency of the population and countries involved with regards to international interventions 

Isabelle URSEAU, January 2002.

Bibliography

Landmine Victim Assistance World Report 2001, Lyon : Handicap International, 2001.
Pour une véritable assistance aux victimes de mines, Lyon : Handicap International, 2000.
Prosthetics and Orthotics Services in Developing Countries, A Discussion document, Geneva : WHO, 1999.
Agir en faveur des personnes handicapées et des groupes particulièrement vulnérables, Lyon : Handicap International, 1998.
Guide pour la formation en prothèse et orthèse dans les pays en développement, Geneva : WHO, 1990.

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Contact :

Orthopaedic techniques :

Isabelle URSEAU

Victim Assistance Focal point :

Nathalie HERLEMONT-ZORITCHAK

Monitoring and policy service

[1]Landmine Victim Assistance World Report 2001, Lyon : Handicap International, 2001.

[2]Guidelines for training personnel for prosthetic and orthotic services in developing countries, Geneva : WHO, 1990.

[3] Ib.

[4] Ib.

[5] Ib.