# Chapter 4: Progress to date and the path ahead

Some countries have already begun making investments and progress in scaling up access to AT, with promising early results.

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.

This chapter highlights recent progress in AT provision within three countries: Rwanda, Pakistan, and the Philippines. Efforts made by these countries offer insight to others looking to increase AT provision within their own borders. Countries need to ensure that their disability- specific and mainstream policies and programmes are developed with an AT-specific lens. Through multi-stakeholder partnerships, public and private actors can support each other in sharing resources to enhance AT delivery capacities and guarantee AT as a core part of the effort to achieve universal health coverage. With proper leveraging of resources and strategic planning, sustainable delivery of appropriate AT is achievable in LMICs.

RWANDA

Rapid scale-up of delivery has allowed the Government of Rwanda to make dramatic strides in providing vision care to individuals in need.

THE CHALLENGE

Rwanda’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

THE APPROACH

Rwanda has created partnerships with key actors to support the scale-up of eye care services. To solve barriers to service delivery, the Government of Rwanda in 2010 partnered with Vision for a Nation, a UK- based NGO, to develop a comprehensive primary eyecare programme that would be incorporated into the national health system. Through three phases, the programme aimed to screen and provide eyeglasses to all Rwandans eight years and older who needed them by 2015.52

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.

LESSONS LEARNED

Rwanda’s innovative efforts in scaling up eye care delivery offer lessons to others. 43 Through this project, the Ministry of Health institutionalised a central fund that allocated revenue from eyeglasses sales solely to the primary eye care programme’s operations.

Rwandan ophthalmologists created a training curriculum for government-employed nurses that is now taught in all eight of the nation’s nursing schools. Furthermore, the programme effectively linked all 42 district hospitals in order to more efficiently serve people with severe visual impairment. These various efforts allowed Rwanda to rapidly scale up supply and delivery chain capacities and effectively provide eyeglasses and medication at all 502 health centres in the country.

PAKISTAN

The Government of Pakistan has led numerous international- and national-level efforts to highlight the importance of increased access to AT.

THE CHALLENGE

Social stigma has excluded people in need of AT from many aspects of Pakistani society and they were overlooked in national plans. 16,55 A lack of data and partnerships on a transnational level made it harder to successfully advocate for their rights

THE APPROACH

To 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

Nationally, steps are also underway to help people in need of AT realise their right to an independent life. Pakistan was the first country to pilot a Rapid Assistive Technology Assessment, surveying a sample of over 9,000 households. While this showed a demand of 13.1% who needed at least one assistive product, it also showed that of those who used an assistive device, 90% had paid for it out-of-pocket and of those who did not have the product they needed, two-thirds said it was because they could not afford it. The data will inform a National Strategic Action Plan with the aim to have universal

access 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 56individuals 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

LESSONS LEARNED

Pakistan has been effective in building an advocacy platform both globally and within its own borders. By leveraging the influence of multi- stakeholder efforts, Pakistan has been able to mobilise countries around the world to support the rights of people with disabilities. This, together with data collection, has also contributed to initial progress in generating domestic political support for the provision of AT.

THE PHILIPPINES

Increased clarity on the unmet need in the Philippines led to radical reform and incorporation of AT in the national health system.

THE CHALLENGE

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.

THE APPROACH

Localised 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

LESSONS LEARNED

Effective data collection and needs assessment efforts have been central to effective AT policymaking at the country level. While national-level surveys provide a wider view of the needs gap in a country, local efforts can target specific gaps in data and contribute to policy improvements. Furthermore, governments should aim not only to mainstream disability in all systems and efforts but also to create disability-specific policies— for instance, within a national health insurance scheme—to support individuals in need.

Systemic barriers to accessing assistive technology must be addressed in order to see the return on investment (ROI)

Despite the progress so far, much work remains to be done and investments are required. While countries such as Rwanda, Pakistan, and the Philippines have taken steps towards meeting the needs of all citizens and promoting their full participation in society, there is a long way to go to guarantee all people access to AT and ensuring their rights. Difficult barriers remain, and it is critical that the world take coordinated action.

Effective AT delivery relies on a supportive policy environment and reliable information; in LMICs, both require strengthening.54 Inconsistent political will and lack of prioritisation for AT can contribute both to obstructive policies (such as exclusion of AT from national health schemes) and unintended consequences (such as stifling import tariffs). At the same time, lack of supporting evidence and inconsistent data make it difficult for policymakers to effectively identify areas where interventions would be most impactful and cost- effective.

Meanwhile, the supply of assistive products does not meet the specific needs of those in LMICs. Few products exist today that are designed specifically for use in LMICs. For example, products may not appropriately fit individual users, prove durable enough for the terrain, or be supported by available maintenance services in the country.7 These challenges stem from a lack of user-centric innovation and inconsistent or inadequate product and service delivery standards. In addition, the lack of participation in LMIC markets on the part of AT manufacturers and suppliers contributes to keeping product availability low and prices high. Products are also unaffordable for users due to inadequate funding for AT and the exclusion of AT from insurance schemes. Finally, a shortage of trained personnel for diagnosis and fitting of AT limits the effectiveness of those products that do reach people in need.

To ensure that all people can access and use the AT they require, new and existing stakeholders will need to coordinate their actions. Effective AT delivery includes a variety of procurement systems and accompanying services including referral, assessment, prescription, ordering, product preparation, fitting and adjusting the product to the user, training the user or family members, follow-up, and maintenance and repairs. Creating these systems cannot happen without prioritisation at the political level, increased resource allocation, a coordinated and collaborative expansion of service offerings in emerging markets, and a commitment from all to overcoming these challenges to support those in need.