The Case for Investing in Assistive Technology
Cover photo (c)UNICEF-UN040610-Pancic
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Physician and Professor of Rehabilitation at Harvard Medical School, Paralympic Gold Medalist
Former UN Special Rapporteur on the Rights of Persons with Disabilities
UN Secretary-General’s SDG Advocate
President, International Paralympic Committee
Well over one billion people around the world require the use of at least one assistive technology (AT); by 2050, the need is expected to double due to ageing global populations, increased prevalence of non-communicable diseases, and other factors. AT is an umbrella term for devices and associated services—from eyeglasses to wheelchairs—that help users 1 live with greater autonomy and choice by improving their functioning in daily activities. Global commitments recognise AT as a human right, yet only 5-15% of the population that needs AT have access to it. This injustice reduces the economic opportunities of individuals, families, and entire nations; not to mention that it comes at a great cost to the quality of life of people who need AT.
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HEALTH IMPROVEMENTS. AT improves users’ health and wellbeing. The health benefits of increased access to the four products and related services are equivalent to an average 1.3 additional years of ‘perfect health’ 2 (quality-adjusted life years or QALYs) over the life cycle of each user. Over the course of users’ lives, AT can facilitate their ability to move, communicate, and see better than before. This directly contributes to improving users’ physical and mental health, while also increasing access to broader health services for ongoing care. Across LMICs, this adds up to over one billion QALYs for those in need today.
Figure 1: Key economic, health and social benefits of AT provision
The Health Benefit is ‘Improve Health and well being’, total lifetime benefits are 1 billion QALYS
Return On Investment is in the ratio of 9:1
The world so far has failed to meet the global need for AT. Well over one billion people today would benefit from at least one form of AT. This need is estimated to double by 2050 due to ageing global populations, increased prevalence of non-communicable diseases, and other factors. 3 Much of this need falls across four products and related services: hearing aids, prostheses, eyeglasses, and wheelchairs. Based on current estimates, nearly one billion people living in low-and middle-income countries (LMICs) require one or more of just these four devices, although the overall need could potentially be significantly greater. Yet only 5–15% of this population have access to AT. 4 This gap is a product of insufficient political will, lack of investment, and numerous systemic supply- and demand-side barriers. Despite efforts to overcome these challenges, access to AT continues to fall short of what is needed—and these essential technologies continue to receive little attention on the global agenda.
Figure 2: Number of people in need of the priority assistive devices*
Assistive technology can contribute to achieving global development targets
2030 Agenda for Sustainable Development
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The Convention on the Rights of Persons with Disabilities
14AT can mitigate institutional and physical barriers and help people contribute to, and benefit from, society on an equal basis with others. People with disabilities make up a large user group of AT. Within the global disability community, AT is recognised as a basic right, and is specifically referenced within the Convention on the Rights of Persons with Disabilities. The Convention states that people with disabilities ‘include those who have long-term physical, mental, intellectual, or sensory impairments, which in interaction with various barriers, may hinder their full and effective participation in society on an equal basis with others.’ 7 The importance of AT in helping to overcome some physical, communication, and information barriers is specifically noted and referenced throughout the Convention. It is a critical component of support, which, alongside non-discrimination and accessibility, is a precondition for inclusion and participation in society.
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Modelling the impact of full access to assistive technology
Our analysis relies on a model developed specifically for this report that incorporates the best-available current data on AT need and the impacts of AT on users’ lives. Because there is insufficient research on disability and AT, data are limited on the potential health and economic benefits of AT, as well as the return on investment in AT provision. Therefore, for our model, we have taken the available data to draw further conclusions based on a set of assumptions (detailed in Annex A). For example, to date, most data relevant to the availability and effects of AT have focused on people with disabilities. Much of what we know about other groups of AT users (including older people, people with chronic health conditions, temporary injuries and diseases) is an extrapolation from this subset of the population. 8
18Figure 3: Economic benefits of AT provision
Assistive technology has a powerful impact on the lifetime earning potential of individual users and their families. The total economic gainsfrom meeting the unmet need for the four ATs across LMICs amount to over USD 10 trillion in real terms over the next 55 years— equivalent to over 1% of total LMIC gross domestic product (GDP) over that period. 9
Table 1: Breakdown of economic benefits from AT access
20Better education has lifelong impact on users’ employment and earnings. Each year of additional schooling a child receives increases future earnings by an estimated 10%. 11 Today, without access to AT, children who need it commonly do not receive the education they require to be successful in the workforce. Providing AT to children in LMICs who need it to attend school—and, once there, to learn to their full potential—would result in average estimated additional lifetime earnings of over USD 100,000 per child today. 12 This is equivalent to an annual average of USD 1,900 per person, or just over 25% of average per-capita income across LMICs.
AT enables children to overcome numerous obstacles to attend school. Children with disabilities, in particular, are between 10 and 60% less likely to attend school than their peers without a disability. 13 The enhanced mobility provided by wheelchairs and prostheses, for example, can help children with disabilities overcome many of the transportation barriers that previously prevented them from attending school. 14
AT also helps children perform better while in class. Challenges within the classroom for children requiring AT are often multi- fold — including inaccessible learning materials, unaccommodating teachers, and attitudinal, physical, and communication barriers— often keeping them from learning to their full potential. 15 Devices such as hearing aids and eyeglasses allow for better engagement with teachers and fuller participation in classroom activities, thus overcoming some of these barriers. 16
21Finally, young users of AT are more likely to finish school than those without access to it. Although data are not available across all AT users, we do know that children with disabilities, many of whom require AT, are approximately one-third less likely to have completed primary school than those without disabilities. 17 With greater academic access, engagement, and chance for academic success, children who need AT are less likely to experience bullying and discouragement and are more likely to complete their schooling.
22Impact of AT access on child learning
Lack of AT limits the employment prospects of many of those who need it and represents a profound barrier particularly for those with disabilities. The last available data across 51 countries from the World Report on Disabilities showed that on average only about half of men with disabilities were employed, compared with two-thirds of men without disabilities. 18 And while specific data in LMICs are limited, WHO highlights that people with disabilities who work are more likely to do so in the informal sector or to hold part-time jobs. 11 , 19
Impact of AT access on a user’s employment opportunities
AT can boost productivity, allowing users to earn more on the job. When people who need AT gain access to it, they are better able to perform daily tasks, communicate with colleagues, and engage with equipment, processes, and systems within the workplace. Inaccessible locations, communication barriers (such as poor lighting or group conversation for someone who lip reads), and structural challenges (e.g. limited promotion opportunities) hinder workers from being as productive as their peers. AT helps overcome only some of these barriers directly, yet our economic model estimates that the four focus products improve a user’s productivity on average by 16%. Research, though scarce, supports this. For example, correcting presbyopia with eyeglasses increased productivity of tea-pickers by 22%, and up to 32% for those aged over 50 years old. 20
25 26without disabilities. 11 , 21 At the same time, people with disabilities and other AT users often must cover high healthcare and other costs (e.g. taxi fare where public transportation is inaccessible). An estimated one in three people with disabilities faces ‘catastrophic health expenditures 22 , compared with one in five people without disabilities. 11 Depressed wages and additional cost burdens are clear contributors to elevated poverty rates among those in need of AT. 11 , 23 To varying degrees, these findings can be extrapolated to other AT user groups.
In much of the world, girls are prevented from achieving the same level of educational outcomes as their male counterparts. Women account for an estimated two-thirds (520 million) of illiterate adults around the world today—the vast majority of whom live in LMICs. 24 There are an estimated 5.5 million more out-of-school girls than boys, and out- of-school girls are more likely than boys never to have enrolled in school in the first place. 25
Already at a gender-based disadvantage in the classroom, girls in need of AT face even greater challenges, resulting in even poorer educational outcomes. For example, survey data found that girls with disability—a large AT user group—are an additional 20% less likely to complete primary school than girls without disability.18 UNICEF has also found that girls with disabilities are particularly at risk of experiencing discrimination and abuse. 31 In the classroom, this manifests as bullying, which may result in poorer mental health or self- esteem and contribute to elevated drop-out rates.
27Adult women face cultural and institutional barriers that present significant barriers to employment and work productivity. Women are traditionally burdened by outsized responsibilities for unpaid care and domestic work. This ‘time poverty’ limits their ability to pursue paid work outside the home. On average, women do three times more unpaid work than men and spend seven more years performing unpaid work over the course of their lifetimes. 26 , 27 , 28 Even when women are empowered to work for pay, numerous barriers limit their productivity and earning potential. For example, in most of Sub-Saharan Africa, women are not awarded with the same land rights as men and often must access land through male relatives. Furthermore, women often face challenges accessing key inputs, such as fertiliser and mechanical equipment, because they are unable to get the credit / financial support they need to purchase these items. 29 This results in a 20–30% productivity gap between men and women working in agriculture in Sub-Saharan Africa. 30
Adult women are further disempowered by a lack of AT. Women in need of AT are even more likely than other women to be left out of the workforce. The same survey data found that just under 20% of women with disability are employed compared with about 30% of women without disability. 25 In addition, women who live in households in which someone else needs AT are disproportionately likely to take on any required support responsibilities. In other words, a lack of access to AT restricts women’s potential even when they are not the prospective users.
28Figure 4: Health benefits of AT provision
Table 2: Breakdown of health benefits from AT access
30Based on the experiences of AT users, providing the four products to those who need them in LMICs would produce an average of 1.3 ‘quality-adjusted life years’ per person. A quality-adjusted life year (QALYs) provides a ‘common currency’ to assess the benefits of health-related interventions on a person’s quality of life. They measure ‘lives improved’ One QALY represents a year of life with ‘perfect health.’ It expresses how much an individual’s ability to, for example, conduct day-to-day activities free of pain and mental distress, incorporating such factors as mobility restrictions, ability to independently self-care, and engagement with work and leisure, changes before and after the intervention.28 For example, a child who continues to receive the prosthetic device needed over their lifetime will on average see an improvement worth 8.9 QALYs – the equivalent of 8.9 years of ‘perfect health.’ Providing the four products to the 900 million people in LMICs who need them would collectively produce the equivalent of over one billion years of perfect health. 32
These benefits come from a combination of improved physical and mental health and increasing access to existing health services. Although AT alone does not constitute a complete solution and systems and societies still need to become more inclusive and accessible, 33 WHO has noted improved health outcomes among users after receiving AT. 11 , 11 The primary driver of these gains is greater access to, and utilisation of, health services. While current evidence is inconsistent, lived experience speaks to reductions in secondary conditions, such as pressure sores amongst wheelchair users, and increased ability to engage in healthy personal habits following uptake of properly fitted AT. Many users are also better able to avoid accidents and identify and respond to threats to personal safety.
31Increased use of AT is directly linked to improved physical and mental health by preventing or reducing the impact of secondary conditions. Both the US Center for Disease Control and Prevention (CDC) and WHO report that people with disabilities, as a subset of AT users, are often at a higher risk of experiencing from secondary conditions related and unrelated to their disability, such as obesity, diabetes, and chronic fatigue. 11 , 34 Research on AT and the reduction of pressure sores has so far been mixed, but hearing aids have been shown to reduce incidence and severity of dementia as well as improving balance and reducing falls. 35 , 36 , 37 At a basic level, access to AT is likely to improve health outcomes simply through facilitating increased mobility and physical activity.
No less critically, AT can have a profound effect on the mental health of users. Dealing with barriers (including stigma) and feelings of isolation, among other daily challenges for those in need of AT, can increase stress and contribute to negative mental health outcomes. Data show that people with physical disabilities, among other AT users, are three times more likely than the general population to experience depression. 38 , 39 AT can be an important tool for helping users overcome some of these barriers and better engage with those around them.
II. Greater access to care services
AT can help people overcome widespread barriers to accessing healthcare services. Many people in need of AT must overcome physical barriers—such as lack of accessible and affordable transportation—in order to access health services. For example, across lower-income countries, a reported 30% of people with disabilities (compared with less than 20% of those without disabilities) could not access healthcare due to transportation costs—such as the added expense of taxis or ride-shares when public transit is inaccessible. 11 People who need AT often also contend with communication barriers, attitudinal barriers within health facilities, lack of services, and inappropriate treatment options—all of which contribute to the fact that individuals with disabilities in lower-income countries are three times more likely to be denied treatment than those without disabilities. 11 While AT cannot address all of these barriers, it plays an important role in helping users overcome some of them.
32Access to AT can improve the mental and physical health of supporting family members by reducing their fatigue and anxiety and freeing up more time for other activities. Family members of those needing AT have been shown to face significantly greater risk of mental distress, including elevated rates of depression, anxiety, and suicide. 40 Further, data have shown that the leading reason parents of people with disabilities fail to seek out mental health services is a lack of time amidst existing support-giving responsibilities. 40 Just as AT use alleviates users’ needs for some forms of support and can free up time for family members to engage in paid work, it can also mitigate the levels of stress and fear that family supporters experience and enable them to seek out formal health services. Thus, the family and community members who support AT users often see improvements in their own wellbeing.
33How a wheelchair benefits a whole family
Greater access to preventive care can reduce total longer-term health system expenditures. Primary and preventive healthcare is significantly cheaper and more cost-effective than curative tertiary and referral-based care. 41 By facilitating greater utilisation of preventive services, and thereby preventing the development of more serious comorbidities, AT can contribute to savings across national-level health systems. At the same time, data also suggest that in some cases these savings may be offset by the significant increase in total healthcare consumption among AT users as they overcome some of the barriers they currently face to accessing all care. However, even if overall health spending may go up, improved access to health services for more people is fundamentally a good thing, contributing to a healthier workforce, which is a more productive workforce. This further contributes to the economic gains discussed above and more than offsets any increase in health expenditure.
Investing in increased AT provision ultimately represents an important step for countries towards the achievement of universal health coverage. One of the targets of the SDGs, universal health coverage (UHC), is a commitment to ensuring that ‘all individuals and communities receive the health services they need without suffering financial hardship.’ UHC includes ‘the full spectrum of essential, quality health services, from health promotion to prevention, treatment, rehabilitation, and palliative care’. 42 Given the range of health and other benefits AT facilitates for users, AT must be a critical part of UHC packages.
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AT can help users more safely navigate their environment and engage with one another. Hearing aids, wheelchairs, prostheses, and eyeglasses improve users’ safety when navigating outside the home by helping them avoid accidents and identify and respond to threats to personal safety. Eyeglasses, for example, contribute to greatly reducing traffic fatalities for drivers. 43
36Figure 5: Social benefits of AT provision
I. (Re)integration of users into society
AT is an important tool for helping adults and children meaningfully engage in their communities and build and maintain social relationships. Older people and adults with disabilities may become socially isolated because they are unable to attend social gatherings or even regularly leave the home. Likewise, children unable to attend school miss out on interacting with their peers and establishing social relationships. Lack of widespread awareness and misconceptions of these issues also often lead to social stigma and further exclusion, which severely detracts from people’s quality of life. AT can facilitate increased interpersonal interaction, which ultimately promotes a sense of belonging, elevates users’ self-esteem, 44 and helps build more resilient and effective communities.
Increased access to AT has also been shown to increase children with disabilities’ engagement in meaningful group play with their peers. This can benefit child development in areas such as confidence, resilience, self-awareness, and independent thought. 45
Access to AT ultimately increases the effectiveness and resilience of a society by increasing the diversity of its engaged members. When more people are able to achieve their full potential, they contribute to the overall wellbeing and diversity of their communities, bring a wider range of perspectives to bear on social issues, and enrich society as a whole. 46 , 47
38II. Living a more independent and fulfilled life
39Impact of AT access on girls in vulnerable circumstances
Nirmala and Khendo were seven when the earthquake struck Nepal in April 2015.
Nirmala was trapped under a collapsed wall and Khendo was buried under the ruins of her house.
While the investment required is substantial, realising the vastly greater economic benefits from increased AT access would lead to a return on investment of 9:1. In other words, for each dollar invested in AT, there is nine dollars in return to users, families and the national economy. 48 As this estimate does not account for the non-financial health and social benefits that AT delivers to users and their communities, the overall benefits of these investments are significantly higher.
The ROI shows that this is a ‘smart buy’ for donors and governments alike. A 9:1 ROI ratio puts investments in expanded access to AT on a par with other important and impactful global initiatives, such as WHO’s ‘Best Buys for NCD Prevention’ 49 and improved childhood education 50.
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Access to AT is gaining global momentum as a policy issue. While more common in higher-income countries, policies supporting AT provision are emerging in LMICs. 51 Through international advocacy efforts, strengthening markets, and national-level policy changes, a number of LMICs have successfully increased their support for the rights of people with disabilities and others in need of AT.
44Rwanda’s capacity limitations have restricted its ability to establish effective service delivery models for eye care services. The number of vision specialists in Rwanda was for a long time inadequate to meet the nation’s treatment need: as of 2013, only four optometrists and ten ophthalmologists served ~1.1 million people requiring vision care. 43 , 52 Moreover, most eye care services were concentrated in the capital of Kigali, making access to care difficult for people in rural areas. 53
As a result of these efforts, Rwanda became the first low-income country to provide universal eye care for its population. 54 The programme’s success can be attributed to rapidly scaling up health personnel capacity. Two thousand Rwandan nurses had been trained in primary eye care by 2016. 50 By 2018, the partnership had sent specialist nurses to all 15,000 communities in Rwanda. 54 The impacts of the programme can be seen across both treatment and eyeglasses delivery. During the first 27 months of the programme, 500,000 screenings were completed, 225,000 individuals received necessary prescription medication, and 65,000 eyeglasses were delivered.43 While there remains much to do to ensure full access to services for people in need of other assistive devices, this represents an important milestone in delivering AT on a national scale.
45To address the lack of knowledge and regional will to act, Pakistan has become a global advocate and international leader in revising policy to address the needs of people with disabilities and others requiring AT. Pakistan sponsored the 2018 World Health Assembly (WHA) resolution on AT, the first ever, 56 and it hosted the first WHO regional meeting on the importance of AT in May 2018. 57 Dr. Sana Hafeez, a physician in Lahore who uses a wheelchair, was named the first-ever WHO Global Champion for AT. 58
46access to AT by 2030. In the meantime, the government has developed a strategic AT action framework due to be launched soon. 56 In March 2019, Prime Minister Khan launched the Ehsaas Kifalat programme with the goal of reducing inequality and investing in vulnerable groups. 11 , 59 In support of the programme’s efforts to provide universal access to AT, the government will provide Sehat Insaf (health identification) cards to people with 56 individuals needing prostheses in 20 under-privileged districts. Further, to continue to expand the availability and uptake of AT, the Government of Pakistan forged a partnership with the Chinese Disabled People’s Federation. 55
Lack of data on the extent of unmet AT need in the Philippines has historically prevented effective policymaking. UNICEF has highlighted the degree to which minimal recognition or diagnosis of health conditions and impairments has long hampered effective data collection in the Philippines. 60 This was driven in large part by stigma and barriers to accessing quality services for those with disability or impairment. 61 For example, while parents may have been aware that their child had a health condition/impairment or disability, they were often unsure of the implications of this or what support might be available. Without an accurate understanding of the gaps in provision, the government struggled to make the necessary policy changes and develop more effective national plans.
47Localised data collection efforts contributed to fundamental changes in the coverage and incorporation of AT in the national health system. Amputee Screening via Cellphone Networking (ASCENT), a mobile application that provides amputees with doctors’ real-time diagnoses and advice on prostheses use, was instrumental in reaching underserved communities. 62 Data gathered from this initiative contributed to the Philippine Health Insurance Corporation (PhilHealth) creating a new benefits package, called Z-MORPH, that targeted people in need of prostheses. 63 , 64 The package was originally limited to providing PHP 15,000 (approximately USD 300) for a lower limb prosthesis but was later expanded to also cover PHP 75,000 (approximately USD 1,500) for above- the-knee prostheses. 65
Building on initial reforms, PhilHealth continued to expand coverage to other groups, amplifying the benefit package’s effects. In 2016, PhilHealth announced that it would be creating benefit packages that would cover children with hearing, visual, mobility, and neurodevelopmental disabilities. 66 In 2018, the company rolled out two packages: the Z Benefit Package for children with developmental disabilities and the Z Benefit Package for children with physical disabilities. 67 The mobility package includes assessment, rehabilitation, and fitting of a prosthesis or wheelchair. In 2019, the government supported a mandate for PhilHealth to expand on these packages to provide coverage for all people with disabilities. 68
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Providing access to assistive technology can improve the lives of hundreds of millions of people
Governments and donors have a responsibility to prioritise action and investment in AT. In 2015, all countries agreed to the Sustainable Development Goals, which include a commitment to achieve Universal Health Coverage (UHC) by 2030. UHC is about ensuring that people have access to the health care they need without suffering financial hardship. Countries will not achieve UHC unless they strengthen their health systems to include equitable provision of quality AT. The need for AT will only continue to grow in coming years as the global population ages. 69 Total need is projected to increase to two billion individuals by 2050.3 Countries will need to explore innovative approaches to creating supportive systems and healthy markets in order to ensure successful AT provision on the required scale. These actions are critical to ensure the human rights of people in need and create more inclusive societies.
Three parameters defined the scope of this work:
priority products for increased utilisation. We selected these four for two reasons: a majority of people in need of AT require at least one of these four products, and the research into their potential benefits is relatively extensive. 71
A set of underlying global assumptions support the model. These include:
The cohort sizes used are shown in Table 3.
Table 3: Estimated cohort sizes, by product and age group 73
| CHILDREN | ADULTS | |
|---|---|---|
| HEARING AIDS | 4 million | 50 million |
| PROSTHESES | 5 million | 30 million |
| EYEGLASSES (prescription) | 20 million | 110 million |
| EYEGLASSES (readers) | - | 720 million |
| WHEELCHAIRS | 10 million | 50 million |
DISCOUNT FOR TIME TO STRENGTHEN AT DELIVERY SYSTEMS
We based the estimate of increase in employment and productivity on previous work by the ILO. The approach accounts for changes in both willingness / capacity to work (workforce participation) and ability to obtain a job (employment and unemployment rates) based on disability severity and the impact of AT. The model estimates the total earnings gains based on the following formula: 74 , 75
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The educational component is based on the impact of increased schooling on lifetime earning potential. Research has shown that each additional year of schooling is linked to a 10% increase in personal earnings. 11 The model scaled each year of school for which a child had AT by the relative increase in ability to attend and perform to estimate the effective number of increased school-years gained. Due to the limited available data regarding the impact of AT on education attendance and performance, the model again used QALY weight values as proxies for increased ability to attend and learn. We then multiplied the result in order to estimate lifetime earnings gains. The following formula describes this calculation: 76
Supporters’ income increases derive from their pre- and post- intervention employment statuses. The model differentiates between those working part-time (‘high’ = 25 hours per week; ‘low’ = 15 hours per week) or not working (zero hours per week) pre- intervention and then accounts for changes between groups post- intervention. Only three of these transitions produce employment gains: i) no work to low part-time work, ii) no work to high part- time work, and iii) low part-time work to high part-time work. We determined the allocation to each category based on average employment statistics for the AT users and the severity of the user’s disability (again using QALY weights as a proxy). 77
The following formula captures the estimated annual income gains from this increase in paid work:
Table 4: Breakdown of modelled economic benefits
65The health impact assessment is based on the quality-adjusted life year (QALY). This is a standard metric used to capture changes in AT users’ reported quality of life, despite a lack of direct change to their underlying physical condition as a result of receiving AT. 79 Existing literature provides data on users’ reported quality of life before and after receiving either of the four assistive products. These data tracked changes in quality of life over the residual life expectancy, beginning with the average age of receiving each AT product (addressing adults and children separately), in order to estimate the total gain in QALY.
The QALY weightings are based on pre- and post-intervention EQ-5D values (a standardised instrument used to measure health status) available in the existing literature. 80 , 81 , 82 , 83 Given the data-poor environment, some of these estimates came from small-scale or localised studies. The QALY weighting values used in the model are shown in Table 5 below.
Table 5: QALY weightings by product (EQ-5D)
66We estimate the gain in QALYs using the following equation: 84
Table 6: Breakdown of modelled health benefits
68The user-incurred costs begin with one-off case-finding activities. These costs are based on benchmark estimates from comparable health interventions, scaled to the prevalence of unmet need for each AT product. 85 , 86 These benchmarks considered health worker wages, transportation, field training, and screening and diagnostic tests.
Users then experience additional recurring costs over the rest of their lifetimes. Across the support provision pathway, individuals typically require appointments for initial referral to a specialist, detailed assessment, AT fitting and training, and subsequent regular follow-up and servicing. 87 Meanwhile, equipment needs typically include the device itself and ongoing replacement parts (depending upon equipment type and usage patterns). To estimate procurement costs, the model uses estimated LMIC market prices for each product. 88 To approximate the cost of delivery, fitting, and training we used WHO estimates of outpatient costs for primary-level hospitals in selected LMICs. 89 Given the lack of data on AT-specific delivery channels, this estimation aimed to reflect the cost of health worker time and any tests necessary to accurately diagnose and prescribe appropriate AT to individuals who need it. These costs, as well as servicing and maintenance, recur over the lifetime of the equipment, starting at an estimated ‘midpoint age’ of receiving AT. 90
69Combining these elements, the model follows this formula:
![Cost per individuals is One-time costs (case finding) + (diagnosis) + Recurrent costs is [[( procurement) + (fitting and training) + (total servicing)] * (user life expectancy upon product lifetime)] product lifetime is number of repetitions](images/p_69.jpg)
Table 7: Breakdown of modelled cost 91
70We estimated the final roi using the following equation:
This includes a summation of the economic benefits across all three drivers. It excludes the health and social benefits also described above, meaning the true ROI (including both financial and nonfinancial benefits) could be even higher than the value estimated here implies. The dollar values of both the benefit and cost components are also discounted according to their net present value 92 with a discount rate of 5% over the AT users’ remaining lifetimes (55 years from start). Given total discounted costs of USD 400 billion, yielding total discounted benefits of USD 4.1 trillion, the model gives a final ROI of approximately 9:1.
Figure 6: Sensitivity analysis findings
Sensitivity of ROI output based on input parameter variation
Ratio of percent-change in ROI to percent-change in input parameter value
1. All AT users, with emphasis on two of the larger populations comprising this group: persons with disabilities and older AT users ↩︎
2. This is estimated in terms of quality-adjusted life years (QALYs)—a measure of an individual’s ability to conduct day-to- day activities free of pain and mental distress, incorporating such factors as mobility restrictions, ability to independently self-care, and engagement with work and leisure. ↩︎
3. World Health Organization. Assistive technology. Available from: https://www.who.int/news-room/fact-sheets/detail/assistive-technology [Accessed 29th October 2019]. ↩︎
4. Rohwerder B. Assistive technologies in developing countries. Institute of Development Studies, 2018. ↩︎
5. Humphreys G. Technology transfer aids hearing. Bulletin of the World Health Organization. 2013;91(7): 471-472. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3699802/ [Accessed 12th January 2020]. ↩︎
6. AT2030 and ATscale. Increasing access to wheelchairs and related services in low and middle income countries, 2019. https://atscale2030.org/ ↩︎
7. UN General Assembly, Convention on the Rights of Persons with Disabilities. 2007. Available from: https://www. un.org/ disabilities/documents/convention/convoptprot-e.pdf [Accessed 10th January 2020]. ↩︎
8. This report draws on existing literature to estimate the unmet need for AT and its potential impact on users lives. This literature has to date been heavily focused on people with disabilities; these limitations are noted where relevant, though the insights from such studies are also applied to model and predict the impact of AT on other types of users. ↩︎
9. This estimate is based on pre-COVID19 data and projections of LMIC GDP growth. We do not expect COVID19- related disruptions to have a significant effect on the aggregate outcomes given the 55-year timeframe. ↩︎
11. Banks LM, Polack S. The economic costs of exclusion and gains of inclusion of people with disabilities. International Centre for Evidence in Disability, 2014. ↩︎
12. This global estimate is in real dollars and accounts for projected inflation over the lifetime of a child today. We also assume that education is otherwise available to those receiving AT, and that there exists a broader array of employment opportunities for users in adulthood (with the benefit of AT). ↩︎
13. Filmer D. Disability, poverty, and schooling in developing countries: Results from 14 household surveys. The World Bank Economic Review, 2008;22(1): 141-63. Available from: http://documents.worldbank.org/curated/ en/279081468333856724/ pdf/775610JRN02008000PUBLIC00Disability.pdf [Accessed 10th January 2020]. ↩︎
14. Greenstone M, Looney A. Education is the key to better jobs. Available from: https://www.brookings.edu/blog/ up- front/2012/09/17/education-is-the-key-to-better-jobs/. [Accessed 14th February 2020]; Dalberg analysis. ↩︎
15. UNICEF. Do children with disabilities attend school? New findings from Sierra Leone. Available from: https:// blogs.unicef. org/evidence-for-action/children-disabilities-attend-school-new-findings-sierra-leone/ [Accessed 15th January 2020]. ↩︎
16. Saleem S, Sajjad S. The scope of assistive technology in learning process of students with blindness. International Journal of Special Education. 2016;31(1): 46-54. Available from: https://files.eric.ed.gov/fulltext/ EJ1099969.pdf [Accessed 14th February 2020]. ↩︎
17. UNESCO. Disabilities and education. Available from: http://www.unesco.org/new/fileadmin/MULTIMEDIA/HQ/ ED/pdf/ Facts-Figures-gmr.pdf ↩︎
19. United Nations. Disability and Development Report: Realizing the sustainable development goals by, for and with persons with disabilities, 2018. ↩︎
20. Reddy, PA, Congdon, N, Mackenzie, G, Gogate, P, Wen, Q, Jan, C, Clarke, M, Kassalow, J, Gudwin, E, O’Neill, C, Jin, L, Tang, J, Bassett, K, Cherwek, DH and Ali, R. Effect of providing near glasses on productivity among rural Indian tea workers with presbyopia (PROSPER): a randomised trial. Lancet Glob Health. 2018;6(9):e1019-e1027. ↩︎
22. WHO defines ‘catastrophic expenditure’ as ‘out-of-pocket spending for health care that exceeds a certain proportion of a household’s income with the consequence that households suffer the burden of disease.’ While thresholds for catastrophic spending vary, WHO has proposed that ‘health expenditure be viewed as catastrophic whenever it is greater than or equal to 40% of a household’s non-subsistence income, i.e., income available after basic needs have been met. ↩︎
23. Mont D, Cuong NV. Disability and poverty in Vietnam. The World Bank Economic Review, 2011;25(2): 323-59. Available from: http://documents.worldbank.org/curated/en/793841468320699746/ pdf/812700JRN0WBEc00Box379814B00PUBLIC0.pdf [Accessed 16th February 2020]. ↩︎
25. UNICEF. Gender and Education. Available from: https://data.unicef.org/topic/gender/gender-disparities-in- education/ [Accessed 31st March 2020]. ↩︎
26. UN Women. Progress of the world’s women 2015-2016: Transforming economies, realizing rights, 2015, ↩︎
27. Dalberg analysis; Estimated using the average unpaid work hours per day across girls and adult women compared to boys and adult men multiplied by the average life expectancy for men and women globally. Data on girls and boys time use from UNICEF ; data on adult time use from UN Women. ↩︎
28. QALYs are the accepted standard for measuring the impact of interventions on an individual’s life in cases where the intervention does not change their underlying physical condition. ↩︎
29. Meinzen-Dick R. Empowering Africa’s Women Farmers. Available from: https://www.project-syndicate. org/commentary/women-farmers-africa-gender-equality-agriculture-by-ruth-meinzen-dick-2019- 10?barrier=accesspaylog [Accessed 31st March 2020]. ↩︎
30. The World Bank. Levelling the eld: Improving opportunities for women farmers in Africa, 2011. ↩︎
31. UNICEF. Assistive technology for children with disabilities: Creating opportunities for education, inclusion and participation, 2015. ↩︎
32. The concept of gaining additional QALYs does not suggest that these individuals will necessarily live longer, but rather it captures improvements in their quality of life due to the ability to move, hear, and see better than before. ↩︎
33. Users may still be forced to contend with inaccessible medical equipment, health professionals who do not fully understand their needs, and low-quality treatment services. ↩︎
34. US Centers for Disease Control and Prevention. Disability and health related conditions. Available from: https:// www.cdc. gov/ncbddd/disabilityandhealth/relatedconditions.html [Accessed 12th January 2020]. ↩︎
35. Mahmoudi E, Basu T, Langa K, McKee MM, Zazove P, Alexander N, et al. Can hearing aids delay time to diagnosis of dementia, depression, or falls in older adults? Journal of the American Geriatrics Society. 2019;67(11): 2632-9. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs. 16109 [Accessed 22nd March 2020]. ↩︎
36. Lin F, Ferrucci L. Hearing loss and falls among older adults in the United States. Archives of internal medicine. 2012;172(4): 369-71. Available from: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1108740 [Accessed 22nd March 2020]. ↩︎
37. Rumalla K, Karim AM, Hullar TE. The effect of hearing aids on postural stability. The Laryngoscope. 2015;125(3): 720-3. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1002/lary.24974 [Accessed 22nd March 2020]. ↩︎
38. Noh JW, Kwon YD, Park J, Oh IH, Kim J. Relationship between physical disability and depression by gender: A panel regression model. PloS One. 2016;11(11). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC5130183/ [Accessed 12th December 2019]. ↩︎
39. A study in Nigeria found that ‘elderly people with hearing loss have higher rates of depression, reducing their interesting in daily activities, with 62% reporting depression symptoms as opposed to 17% for those without hearing loss.’ (Sogebi OA et al. 2015.) ↩︎
40. Gilson KM, Davis E, Johnson S, Gains J, Reddihough D, Williams K, et al. Mental health care needs and preferences for mothers of children with a disability. 2018;44(3): 384-91. Available from: https://onlinelibrary. wiley.com/doi/abs/10.1111/ cch.12556 [Accessed 8th March 2020]. ↩︎
41. World Health Organization. Building the economic case for primary health care: a scoping review, 2018. ↩︎
42. World Health Organization. Universal health coverage. Available from: https://www.who.int/news-room/fact- sheets/detail/ universal-health-coverage-(uhc) [Accessed 14th January 2020]. ↩︎
44. Alquraini T, Gut D. Critical components of successful inclusion of students with severe disabilities: Literature review. International Journal of Special Education. 2012;27(1): 42-59. Available from: https://files.eric.ed.gov/ fulltext/EJ979712.pdf [Accessed 14th February 2020]. ↩︎
46. World Economic Forum. The business case for diversity in the workplace is now overwhelming. Available from: https://www.weforum.org/agenda/2019/04/business-case-for-diversity-in-the-workplace/ [Accessed 8th March 2020]. ↩︎
48. This estimate includes an adjustment for the ‘net present value’ of all costs and benefits, discounting those that accrue over time. The discounted value of all economic benefits comes to USD 4.1 trillion, while discounted costs total USD 400 billion. ↩︎
49. World Health Organization. Saving lives, spending less: A strategic response to noncommunicable diseases, 2018. ↩︎
50. Global Partnership for Education. Fund education, shape the future: Case for investment, 2017. ↩︎
51. This may be in the form of AT inclusion in disability policy, AT-specific policy (including but not limited to users with disability), and/or the mainstreaming of AT into other national health policies. ↩︎
52. Ingber J. Vision for a nation provides access to eyeglasses for Rwandans. Available from: https://www.afb.org/aw/14/5/15692 [Accessed 9th December 2019]. ↩︎
53. Binagwaho A, Scott K, Rosewall T, Mackenzie G, Rehnborg G, Hannema S, et al. Lessons from the field: Improving Eye Care in Rwanda. Bulletin of the World Health Organization. 2015;93: 429-34. Available from: https://www.who.int/bulletin/volumes/93/6/14-143149/en/ [Accessed 9th December 2019]. ↩︎
54. Bowman V. Rwanda becomes first poor country to provide eye care for all. Available from: https://www. theguardian.com/ global-development/2018/jan/31/rwanda-becomes- rst-poor-country-to-provide-eye-care-for-all [Accessed 9th December 2019]. ↩︎
55. The Economist Intelligence Unit. Moving from the margins: Mainstreaming persons with disabilities in Pakistan, 2014. ↩︎
56. World Health Organization Pakistan Country Office. Personal Communication. 28th January 2020. ↩︎
57. World Health Organization. Pakistan hosts groundbreaking meeting to improve access to assistive technology. Available from: http://www.emro.who.int/pak/pakistan-news/pakistan-hosts-groundbreaking-meeting-to-improve-access-to-assistive-technology.html [Accessed 24th January 2020]. ↩︎
58. World Health Organization. Pakistani Doctor Sana Hafeez Named WHO Global Champion for Assistive Technology. Available from: http://www.emro.who.int/pak/pakistan-news/pakistani-doctor-sana-hafeez-named- who-global-champion-for-assistive-technology.html [Accessed 24th January 2020]. ↩︎
59. Government of Pakistan. Ehsaas Programme, Prime Minister’s policy statement. Available from: http://www. pakistan.gov. pk/ehsaas-program.html [Accessed 24th January 2020]. ↩︎
60. UNICEF. No Child Left Behind: Study Calls for Better Care of Children with Disabilities. Available from: https:// www.unicef. org/philippines/press-releases/no-child-left-behind-study-calls-better-care-children-disabilities [Accessed 8th January 2020]. ↩︎
61. Jaucian D. Breaking the Stigma on Filipino Children with Disabilities. Available from: https://cnnphilippines. com/life/ culture/2017/03/03/lotta-sylwander-interview-unicef.html [Accessed 8th January 2020]. ↩︎
62. Valmero. Mobile app helps Filipino amputees in remote areas. Available from: http://www.science.ph/full_story. php?type=News&key=5553:mobile-app-helps-filipino-amputees-in-remote-areas [Accessed 8th January 2020]. ↩︎
64. PhilHealth. President PNoy leads launch of PhilHealth’s prosthesis benefit package and new provider payment mechanism. Available at: https://www.philhealth.gov.ph/news/2013/prosthesis_benefit.html [Accessed 8th January 2020]. ↩︎
65. AT2030 and ATscale. A market landscape and strategic approach to increasing access to prosthetic and related services in low and middle income countries, 2020. https://atscale2030.org/ ↩︎
66. PhilHealth. Improving Access to Assistive Technology and Rehabilitation for Children with Disabilities (CWD). Available from: https://www.philhealth.gov.ph/news/2016/assistive_tech.html [Accessed 8th January 2020]. ↩︎
67. Castillo. Guide to PhilHealth’s Z Benefit Packages for kids with disabilities. Available from: https://www. smartparenting. com.ph/parenting/kids-with-special-needs/philhealth-benefit-package-children-special-needs- disabilities-a00026-20180305 [Accessed 8th January 2020]. ↩︎
68. PhilHealth. PhilHealth to Introduce Special Benefits for PWDs. Available from: https://www.philhealth.gov.ph/ news/2019/ pwd_bnfts.php [Accessed 8th January 2020]. ↩︎
69. Special Rapporteur on the Rights of Persons with Disabilities. Report of the Special Rapporteur on the rights of persons with disabilities (theme: older persons with disabilities), 2019. ↩︎
70. Note that residual life expectancy is based on an average across those without access to AT today. Among children in need, we assigned average ages of receiving AT by product; we estimated residual life expectancy as the difference between average life expectancy at birth across LMICs and these average ages (by product) of receiving AT. ↩︎
71. We did not include ATscale’s fifth priority product—assistive digital devices and software—because the range of products in this category is much broader and ATscale’s scope of work in this area is not yet defined. ↩︎
72. This is a conservative assumption on the costing side of the model; ATscale aims to facilitate long-term price reductions through its market shaping work, significantly reducing the costs of delivering products in LMICs and thus further improving the cost-effectiveness of future investments in this space. ↩︎
73. based on estimates in the Product Narratives developed by AT2030 and ATscale (atscale2030.org/product- narratives) ↩︎
74. Buckup S. The price of exclusion: The economic consequences of excluding people with disabilities from the world of work. International Labour Organisation. 2009. Available at: ilo.org/employment/Whatwedo/Publications/working-papers/ WCMS_119305/lang--en/index .htm [Accessed 24th October 2019]; adapted by Dalberg for this analysis. ↩︎
75. This assumes i) average employment statistics can be applied to estimate LMIC-wide shifts, and ii) working life spans from the ages of 18 to 64. ↩︎
76. Although this increase in educational performance drives increased earnings while employed, the model does not explicitly account for additional changes to likelihood of employment beyond that shown in the employment and productivity formula above. ↩︎
77. The allocation to pre-intervention categories assumed that the supporters of any AT user currently working or seeking work would not be providing full-time care. Among those working part time, we determined the allocation to the ‘high’ and ‘low’ categories by the users’ workforce participation rate weighted by their pre-intervention QALY score. For the post-intervention distribution, the model also assumed that no support provider performed less paid work than before the intervention. ↩︎
79. While AT does not itself change a user’s physical condition, some AT does contribute to subsequent changes in physical health, e.g., prostheses improving ability to exercise, wheelchairs reducing risk of some secondary conditions, etc. QALY metrics capture these impacts. ↩︎
80. Davies A, Souza LD, Frank AO. Changes in the quality of life in severely disabled people following provision of powered indoor / outdoor chairs. Disability and Rehabilitation. 2003;25(6): 286-90. Available from: https://bura. brunel.ac.uk/ bitstream/2438/3367/1/epioc%202002.pdf [Accessed 11th November 2019]. ↩︎
81. Persson J, Husberg M. Can we rely on QALYs for assistive technologies? Technology and Disability. 2012;24(1): 93-100. Available from: https://www.researchgate.net/publication/235641799_Can_we_rely_on_QALYs_for_ assistive_technologies [Accessed 17th November 2019]. ↩︎
82. 59. Park Y, Shin JA, Yang SW, Yim YW, Kim HS, Park YH. The relationship between visual impairment and health-related quality of life in Korean adults: The Korea National Health and Nutrition Examination Survey (2008-2012). PLos One. 2015;10(7). Available from: https://journals.plos.org/plosone/article?id=10.1371/journal. pone.0132779 [Accessed 11th November 2019]. ↩︎
83. Pennington M, Grieve R, van der c JH. Cost-effectiveness of five Commonly used prosthesis brands for total knee replacement in the UK: A study using the NJR Dataset. PLos One. 2016;11(3). Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0150074 [Accessed 12th November 2019]. ↩︎
84. Sassi F. Calculating QALYs, comparing QALY and DALY calculations. Health Policy and Planning. Available from: https://www.ncbi.nlm.nih.gov/pubmed/16877455 [Accessed 24th October 2019]. ↩︎
85. Karki B, Kittel G, Bolokon Jr I, Duke T. Active community-based case finding for tuberculosis with limited resources: estimating prevalence in a remote area of Papua New Guinea. Asia Pacific Journal of Public Health. 2017;29(1): 17-27. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5349312/ [Accessed 24th January 2020]. ↩︎
86. Sekandi JN, Dobbin K, Oloya J, Okwera A, Whallen CC, Corso PS. Cost-effectiveness analysis of community active case finding and household contact investigation for tuberculosis case detection in urban Africa. PLos One. 2015;10(2). Available from: https://www.ncbi.nlm.nih.gov/pubmed/25658592 [Accessed 24th January 2020]. ↩︎
87. World Health Organization. Guidelines on the provision of manual wheelchairs in less resourced settings, 2008. ↩︎
90. Shepard DS. The market for wheelchairs, innovations, and federal policy. Congress of the US, Of ce of Technology Assessment. Available from: https://www.princeton.edu/~ota/disk3/1984/8418/841808.PDF [Accessed 24th January 2020]. ↩︎
92. Net present value (NPV) is a method of comparing the values of invested resources and results over time in constant (current) terms in order to determine the overall net return on investment. ↩︎
