CHAPTER 1: MOBILE PHONES AS ASSISTIVE TECHNOLOGY

Chapter Summary: Individuals that require AT can benefit tremendously from the use of mobile phones, especially smartphones. Accessibility features and applications on a smartphone can provide similar assistance to many traditional assistive devices or augment digital assistive technologies. The use of mobile phones enhances independence and productivity, improves access to the digital economy, and democratises access to information. However, penetration of mobile phones and telecommunication services is much lower in low- and middle-income countries (LMICs) than high-income countries (HICs). Moreover, ownership among people with disabilities is lagging compared to the overall population. Barriers to mobile ownership and usage include, but are not limited to, the high cost of devices and network plans, limited awareness and understanding of the benefits of mobile as AT, and limited disability-inclusive designs and limited use of tools that allow for the full use of mobile phones by persons with disabilities. In order to increase access to mobile phones (particularly smartphones) as AT, the following objectives are proposed: 1) support government ministries in adopting policies that promote the use of mobile phones as AT for people with disabilities; 2) increase the affordability of mobile phones for people with disabilities through innovative financing; 3) ensure that people with disabilities can access mobile phones with appropriate feature sets for their individual needs; and 4) increase awareness of the benefits of mobile phones through expanded digital literacy training.

1. Mobile Phone Landscape

Mobile phones (when connected to the mobile/data network) have tremendous benefits for economic, social, and physical well-being. Mobile phones enable economic inclusion through access to financial services, including mobile money, which is used widely in LMICs. When people with disabilities use mobile phones, they provide them with access to government services, including information on health and rehabilitation services, education and skills training, and civic engagement (e.g. voting in elections). Mobile technology reduces barriers in the physical and social environment, increases communication with families and communities, and enables mobilisation through disability rights networks and peer interaction. As services and products are increasingly digitised, mobile phones (with adequate mobile coverage and connection to a mobile and data network) become a critical tool to enable people with disabilities to live independent and socially connected lives. Persons with disabilities perceive that mobile phones enable

access to basic services.14 However, the infrastructure for connectivity to the internet is often limited in LMICs. A 2013 survey found that many LMICs have insufficient broadband and communication services infrastructure, especially for accessing educational content.15 But, as investment increases and countries adapt to the COVID-19 pandemic, this landscape is changing rapidly with the population covered by 3G and/or 4G networks trending upward.

Mobile device technology is advancing rapidly, with innovations quickly replacing older models. ‘Basic’ phones have the lowest functionality, and primarily allow voice calls, SMS (text messaging), and Unstructured Supplementary Service Data (USSD) features, which leverage cellular networks for mobile banking, location-based content, and other information services. These devices have a small, basic screen and limited connectivity functions beyond the mobile network. ‘Feature’ phones contain all the features of a basic phone, but also add low-bandwidth internet access. They may contain multimedia features, including the ability to play video or music. ‘Smartphones’ are the most advanced category of mobile phones and contain many of the functionalities of a computer. The device has a large touchscreen, and can access mobile internet, Wi-Fi, and Bluetooth. The operating system can download and operate a large library of third-party applications to create customised functionality and user experience. These applications, such as mobile-enabled screen readers and AACs, allow the smartphone to serve as AT. Smartphones are often able to connect to auxiliary devices through Bluetooth, which enables users to create modular digital AT that are typically lower in cost than standalone devices. While smartphones geared towards HIC markets can be priced over USD 1,000, there is an emerging segment of lower-cost ‘Smart Feature Phones’ developed primarily by Chinese manufacturers. These devices rely on a different operating system to the standard Android or iOS, and contain many of the features of a smartphone, but with limited memory and processing power, which can limit functionality. Smart Feature Phones are the fastest growth segment of mobile phones in Africa. See Table 1.

PHASING OUT OF PERSONAL DIGITAL ASSISTANTS

The World Health Organization (WHO) includes personal digital assistants (PDA) in the Priority Assistive Products List. Popularised in the 1990s as new technology, PDAs are digital mobile devices that provide limited organiser functions, which can serve as an assistive tool to digitise certain common tasks (e.g. reminders, calendars, note-taking). Unlike a mobile phone, they do not connect to a network to provide calling, SMS, or internet access, and are usually limited to Bluetooth connectivity. PDAs do not contain a hard drive, which limits storage capacity, and typically have a short battery life. Accessibility features are limited for PDAs, or only found on more advanced models. PDAs are on the lower end of the technology and capability spectrum; hence mobile phones are typically preferred by new adopters of mobile technology. PDAs will not be a focus of this report.

TABLE 1: TYPES OF MOBILE DEVICES (FROM BASIC TO ADVANCED)

Device	Basic Phone	Feature Phone	Smart Feature Phone	Smartphone
Sample image
Functionality	Small screen, voice calls, SMS, USSD.	Small screen, voice calls, SMS, USSD, mobile internet, multimedia player, some pre-downloaded applications.	Some have touch screens, voice calls, SMS, mobile internet, limited storage and operating system (e.g. Android GO or KaiOS), capable of running a limited library of customisable applications. Accessibility features are variable.	Large touchscreen, voice calls, SMS, mobile internet, front and rear camera, powerful storage and operating system (Android or iOS) capable of running customisable applications, accessibility features.
Example brands/models	Nokia (8110), Doro (6620), Light Phone, Easyfone (Prime A1)	Nokia (3300 Dual SIM card), Samsung (Guru/1200), Intex (Eco Beats)	Onyx (Connect), Transsion (Tecno, itel, Infinix), Orange (Sanza)	Apple (iPhone), Samsung (Galaxy Phone), Huawei (Mate 20 Pro), Transsion (Tecno, itel, Infinix)
Pricing	USD 25-USD 50	USD 100-USD 300	USD 20-USD 100	USD 100-USD 1,000+

More than 5.2 billion people worldwide are subscribers to mobile services, with 65% of those connections being smartphones.16 Subscriptions are growing +1.9% per year, with LMICs leading the growth. By 2025, there will be 600 million new subscribers, with 73% from Latin America, Sub-Saharan Africa, and Asia-Pacific (excluding China). 17 The current median ownership rate in HICs stands at 76%, compared to 45% in LMICs. 18 People with disabilities in LMICs report even lower rates of coverage: a study in Kenya and Bangladesh showed a ~13% gap in mobile phone ownership between people with disabilities and people without.19 Mobile phone ownership and usage is also driven by network quality and level of coverage. 20

Accessibility features help enable people with visual, hearing, or cognitive impairments to interact with content on mobile phones (Table 2) that would be otherwise inaccessible. Smartphones often employ universal design. This means that a product is designed to be accessible, understood, and used to the greatest extent possible by all people, regardless of their age or ability.21 The International Telecommunication Union (ITU) and the Global Initiative for Inclusive ICTs (G3ict) promotes accessibility and universal design principles to be incorporated at the earliest stage of the product development to ensure that accessibility is mainstreamed. This limits additional product segments from being specifically created for people with disabilities.

Smartphones typically contain more accessibility features, either built-in or downloaded as an application. Smart feature phones and feature phones will often have fewer or limited accessibility features, while basic phones may have none. Beyond these accessibility features, people with disabilities can download applications or connect with external devices to replace some traditional AT, such as braille readers, AAC, or switches in some cases; the ability to connect to and be interoperable with other devices expands the use case of mobile phones as AT. However, mobile phones may not meet the digital AT needs of all individuals – some may need larger screens, such as tablets, or buttons that are easier to manipulate. When the handset is not designed with good usability and accessibility in mind, it can be worse than a feature for visually impaired people; however, when done well, mobile phones can successfully bridge physical accessibility challenges as well.22

In summary, smartphones offer a wide range of use cases and added value-for-money for people with disabilities or functional limitations; yet ownership is lower compared to the broader population. Over 70% of people with disabilities who are mobile device owners in Kenya and Bangladesh own a basic or feature phone. In Bangladesh, within the broader population, 49% of mobile phone users own smartphones, compared to only 29% of people with disabilities. 23 When persons with disabilities have access to accessibility features, they tend to make higher use of mobile services. 24

TABLE 2: SELECTION OF ITU AND G3ICT RECOMMENDED ACCESSIBILITY FEATURES OF MOBILE PHONES 25

FEATURES	DESCRIPTION
Adjustable display settings (e.g. font size, colour contrast)	To assist people with visual impairments to use mobile devices
Text-to-speech / voice recognition	Enables visually impaired people to access menus/applications, receive audio feedback, or read messages aloud
Pictorial address book / menus	Enables cognitively impaired or non-readers to access contacts and other phone features
Visual or tactile indicators for the keypad and screen	Uses light or other indicators to demonstrate input
Mono audio	Makes listening to music and making calls easier for people with hearing loss affecting one ear
Captioning	Provides text captions for multimedia to assist deaf users

The cost of owning a mobile phone is composed of the cost of the device itself, content (such as applications), and the network tariff plan, which includes airtime and/or data. The latter is on average the most expensive component. Based on average annual costs, 58% is spent on the network plan, followed by the device (25%) and content (17%).26 The GSM Association (GSMA)27 advocates that the total cost of ownership of a smartphone should not exceed 5% of annual income. LMIC users currently spend up to 9% of their income on smartphone ownership, with the lowest income users spending more than 16%.28 People with disabilities often do not have a steady income to pay for a mobile phone.

In Kenya, 55% of people with disabilities who do not own a mobile phone cited that they could not afford the cost of purchasing the phone as the primary barrier to ownership. An additional 9% cited not being able to afford the network plan to access data.29 Additionally, the network tariff plan may not be structured in a way that is adaptable to how people with disabilities use mobile services – for example, users with hearing impairments may only need a text-only or data-only package that does not include voice minutes.30 Affordability challenges are exacerbated by the fact that people with disabilities can benefit from accessibility features that may be limited to higher-end smartphones. Purchasing second-hand smartphones, specifically second-hand iPhones, is one way in which people with visual impairment in India have overcome affordability barriers, for example.

Mobile phones are often not viewed as an assistive product by people with disabilities, their caregivers, or social service or health providers. Digital literacy in LMICs remains a gap for many individuals, and stems from lack of access to devices and internet connectivity, as well as to education and programmes that promote digital skills training. For example, only 50% of African countries have digital or computer skills as part of their school curriculum, compared to 85% of non-African countries.31 Without appropriate training, potential users may not know how to use mobile phones or know that features exist to facilitate access to mobile content. Family and caregivers may also not know about all the features and benefits. Last-mile (mostly rural) mobile phone sellers are often ill-equipped to provide recommendations on the best phone and corresponding features needed to meet the needs of people with disabilities or other limitations. This leaves a gap in awareness, feature- and device-matching, and digital literacy training. NGOs programmes and digital tools such as ATvisor can help fill this gap (See Case Study 1). The Global Accessibility Reporting Initiative (GARI) has created a website to help people with disabilities select the best mobile phones, tablets, apps, Smart TVs, or wearables based on their disability, and to see the accessibility features of each device.32

In addition to selecting the most appropriate device, people with disabilities may benefit from services that help them navigate the extensive list of applications that can be downloaded to a smartphone. Although the proliferation of mobile applications is positive in that it helps meet the unique needs of different users, it can also lead to confusion for people with disabilities. The development of directories or application bundles that serve a particular functional use case can help shorten the pathway for people with disabilities to get to the full suite of mobile applications they need. For example, a directory of vetted applications that can serve the needs of someone with visual impairment may include a screen reader, bank note identifier, talking calculator, and object/light/colour identifier. "App Catalogue", led by UNICEF, is one such project.

CASE STUDY 1: ATvisor

ATvisor.ai is an artificial intelligence-enabled platform that recommends AT that meet the needs of an individual. Founded in 2016, ATvisor looked to fill a gap where people with disabilities and older people had limited awareness and understanding of what devices are most suitable for them. Healthcare professionals and caregivers lack awareness of the different AT on the market and how to fit them appropriately. To address this gap, ATvisor has developed a platform that makes recommendations based on the specific profile of the user, to break down the barriers of awareness and knowledge requirement.

While free for end-users and professionals, ATvisor charges manufacturers and suppliers a fee to be included on their platform. ATvisor has currently only launched in Israel via two closed pilots, on-boarding 200 healthcare professionals, conducting 1,000 personal searches, and connecting to 300 suppliers, and has shipped 20,000 products. On top of matching users to AT, ATvisor has created a database of AT suppliers and products to further illuminate trends in the global marketplace. ATvisor works through a model of collaboration with local partners to enter new markets and sees high potential for their platform in LMICs. 33

The mobile phone industry in LMICs is led by mobile network operators (MNO), who invest in infrastructure, provide mobile network connection and subscription plans, and also work with global suppliers to source devices. Unfortunately, MNOs in LMICs often fail to buy in bulk volumes in order to limit stock risk exposure, leading to higher unit and transport costs for devices. 34 Industry and import taxes are often passed on to the end user. When it comes to distribution, MNOs typically count on independent retailers to sell devices and subscriptions, particularly in rural areas. These retailers may charge high premiums, do not offer full support for the devices, and/or sell unlicensed and outdated devices and components – leading to higher costs to the user. Cost-effective distribution, such as that found in rural Kenya (Case Study 2), could be further replicated and scaled; however, further consideration on how to meet the needs of people with disabilities is needed. This may include training sales and support staff to provide accessible education and device-matching.

In middle- and high-income countries, financing solutions that spread out a large lump-sum payment over time exist to make the purchase of a smartphone more affordable in the short-term to the customer. MNOs bundle the cost of the device with a network plan, whereby the full cost of the device is subsidised because of the guaranteed plan revenue over time – locking in a customer typically for one to two years. Customers pay in instalments. Though widely used in HICs, this structure is challenging in low income economies because of the lack of credit history and user identification. This compounds the challenges people with disabilities often face, as they usually have additional barriers to financing the device. Some MNOs have promoted and created personal savings schemes that leverage community social networks which customise savings to each user’s income stream. These mechanisms also enable users to accumulate sufficient funds to afford a mobile phone. Government and NGO programmes can help with the cost of ownership to people with disabilities by offering device and mobile network plan subsidies or providing low-cost asset financing.

CASE STUDY 2: COPIA

Smartphones are often inaccessible for people at the base of the pyramid market in Kenya. Users must either travel to an urban centre to purchase a phone, incurring travel costs, or buy from grey markets, where prices can be marked up by up to 300% compared to urban retail.

Copia is a mobile retail service for low-income rural and peri-rural people in Kenya, launched in 2013. Copia uses its direct agents to educate and create demand, becoming point of contact for users to own smartphones at retail price. Copia direct agents use tablets with e-catalogues that enable them to offer products without needing the capital to purchase inventory. Customers can have their order for smartphones placed and delivered via a strong local distribution network. Copia also works with local savings organisations to facilitate payment. While agents receive commission, tapping into this network allows more people in rural Kenya to enjoy the benefits of smartphones at prices similar to those found in urban centres.

Since its launch, Copia has expanded its agents from 200 to 1,200, 25-35% of whom sell and distribute smartphones to new areas that were not penetrated by MNOs and phone manufacturers previously. Copia has also expanded to providing items beyond mobile phones to include additional electronic, household, and other goods.

Most LMIC governments lack the policies needed to promote ICT accessibility and the uptake of mobile devices by people with disabilities. Access to mobile devices cuts across the purview of multiple government agencies, such as ICT, social welfare, and health, making co-ordination of efforts and funding difficult. Procurement of mobile devices intended to be used by persons with disabilities should be streamlined through inclusion in national procurement processes and the removal of industry taxes for such users. Furthermore, procurement should include mobile applications that can be downloaded to devices. Investment is needed to expand education programmes and digital skills training. Governments can also help enable people with disabilities access financing for devices through loans, or subsidies for devices and network plans. Beyond access to the device itself, governments should ensure that government services and digital content are designed with accessibility in mind, and can work with employers to incentivise digital skills training programmes and the creation of employment opportunities for people with disabilities.

ITU and G3ict have developed the Model ICT Accessibility Policy Report that provides an overview of key provisions that should be included in primary ICT legislation in order to mainstream ICT accessibility in national regulatory and policy frameworks, which includes modules on mobile communications accessibility and accessible ICT public procurement policies.35 This document can serve as a starting point to provide national policy makers with a generic approach and model text that can be adapted to the country context.

2. Mobile Phone Access Challenges

Demand
Awareness	Low awareness among policymakers, people with disabilities, caregivers, and social service and health providers on the benefits and use cases offered by mobile devices to improve the economic, social, and health well-being of persons with disabilities or individuals with specific functional limitations.
Financing	Upfront costs for a mobile phones are high. People with disabilities generally have lower access to financing schemes and subsidies that are offered to the general population and reduce the upfront investment. As people with disabilities are more likely to be affected by poverty and employment barriers, they face unique difficulties in accessing credit or accumulating sufficient savings. People with disabilities commonly rely on NGOs to provide free or heavily subsidised mobile devices, but these programmes are limited in reach.

Supply
Product Features	Mobile phones that offer the highest value for persons with disabilities are those that contain accessibility features. Although ITU promotes universal design and accessibility features in all mobile phones, these are typically limited to higher-end smartphones. People with disabilities may need better guidance when selecting an appropriate mobile phone.
Cost	Low-volume purchasing, high industry taxation and import costs, and reliance on high-commission last-mile distribution chains all contribute to a high cost to the end user. In addition, the cost of airtime and data on mobile network plans is a significant barrier to mobile usage.

Enablers
Policy	Governments lack policy frameworks that promote mobile phone access for people with disabilities, build awareness for mobile phone use, support MNOs to activate buyers that have a disability or functional limitation, or incentivise innovation in mobile technology and content catered to people with disabilities or impairments.
Digital Literary	LMICs lack programmes and adequate education systems that provide people with disabilities with the digital skills to select, use, and maintain a mobile device, which also inhibits the understanding of the benefits, and presents barriers to purchasing and selection.
Connectivity	Mobile network coverage and quality in LMICs can limit the usability and applicability of mobile phones.

3. Proposed Interventions to Increase Access to Mobile Phones as AT

Strategic Objective 1: Support government ministries to adopt policies that promote the use of mobile phones as AT for people with disabilities.

Rationale

Government leadership is needed to create an enabling policy environment for accessibility and uptake of mobile.
Coordinated planning and funding is required between various ministries that engage with people with disabilities.

Proposed activities

Advocate and provide technical assistance to strengthen cross-ministry coordination between ICT, health, education, labour, and social welfare ministries to: 1) designate mobile and smart phones as AT; 2) develop policies that enable greater access to smartphones for people with disabilities (including the reduction of duties and industry taxation) on the import of phones for people with disabilities); and 3) include procurement and provisioning of mobile and smartphones to people with disabilities under the national disability plan and/or universal health coverage.

Strategic Objective 2: Increase affordability of mobile phones for people with disabilities through innovative financing.

Rationale

High out-of-pocket upfront costs are a major barrier for people with disabilities.
People with disabilities are more likely to be poorer and less bankable than the broader population in LMICs.

Proposed Activities

Provide technical assistance to governments to create financing schemes for people with disabilities to purchase mobile phones, such as provision of loans and subsidies or inclusion in health insurance.
Expand third-party payment methods, including subsidies and personalised pricing based on equity, whereby private companies, governments, or NGOs help offset the cost of ownership.
Encourage LMIC governments and MNO procurement efforts to purchase devices in bulk, enabling volume discounts for both public and private sector provision.

Strategic Objective 3: Ensure that people with disabilities or other functional limitations can access mobile phones with the appropriate feature set for their individual needs.

Rationale

People with disabilities often lack awareness and understanding of the benefits and accessible features of mobile phones and accessible content.
Sales channels in LMICs lack knowledgeable advisors that can recommend and offer appropriate solutions for people with disabilities.

Proposed activities

Support MNOs to create minimum product standards for universal design and accessibility features for phones on their networks, and ensure manufacturers and procurement agents adopt such features.
Encourage MNOs to promote accessibility features to all users, distributors, and retailers of smartphones to drive increased awareness.
Pilot AT recommendation and matching tools (e.g. ATvisor) to advise on AT selection at the individual level in LMICs.
Work with suppliers, governments, and service providers to create application directories or bundles specific to certain disabilities (at a global or local level).

Strategic Objective 4: Increase awareness of mobile phone benefits through expanding digital literacy training.

Rationale	Digital literacy is a major gap for people with disabilities for adoption of mobile phones. Lack of training for health and social service workers to understand and relay the benefits of mobile phone use to people with disabilities.
Proposed activities	Support the scale up of digital inclusion education and skills-building programmes, and create referral mechanisms through schools and the ministry of education. Support relevant government agencies to include digital literacy and device education for community health and rehabilitation care workers who work with people with disabilities and their families.