# NOTES

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. ↩︎

10.Note that value may not equal sum of components due to rounding↩︎

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 ↩︎

18.World Health Organization. World Report on Disability, 2011. ↩︎

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. ↩︎

21.Handicap International. Situation of wage employment of people with disabilities, 2016. ↩︎

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]. ↩︎

24.UNESCO. Better Life, Better Future Campaign. ↩︎

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]. ↩︎

43.World Economic Forum. Eyeglasses for global development: Bridging the Visual Divide, 2016. ↩︎

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]. ↩︎

45.LEGO. Play well report, 2018. ↩︎

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]. ↩︎

47.Deloitte. The economic benefits of improving social inclusion, 2019. ↩︎

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]. ↩︎

63.Professor J. Bundoc, Personal Communication. 10th March 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. ↩︎

78.Note that value may not equal sum of components due to rounding. ↩︎

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. ↩︎

88.AT2030 and ATscale. Product Narratives, 2019-2020. https://atscale2030.org/ ↩︎

89.Data from WHO-CHOICE Project, 2011. ↩︎

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]. ↩︎

91.Note that totals may not equal the sum of the components due to rounding. ↩︎

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. ↩︎