4.2. The Big 5 are focused on premium products to generate market value and have limited commercial interest in L.M.I.C.s.

The Big 5 have a limited presence in non-Western markets. For example, for William Demant, the Asia-Pacific accounts for 21% of unit sales, mostly from Japan and China. South America and Africa account for only 7% and 2% of unit sales, respectively.49 The Big 5 see limited commercial interest in L.M.I.C.s due to the following factors:

• LOW AWARENESS AND STIGMA. Awareness of hearing loss is very low in L.M.I.C.s. Even when people are aware, stigma associated with the use of hearing aids exists.
• LIMITED ACCESS TO HEARING CARE PROFESSIONALS. The low availability of audiologists is often cited as a barrier to scale by many major hearing aid suppliers.
• REGULATORY CHALLENGES. In some L.M.I.C. markets, registration of new hearing aid products can be time-consuming, particularly when compared to H.I.C. markets. In addition, in many L.M.I.C.s low-cost products that are often unregulated exist. Big 5 products cannot compete on price with these low-cost hearing aids and personal sound amplification devices.
• LOW PURCHASING BY USERS OR GOVERNMENTS. L.M.I.C. governments are typically not prioritising hearing aids within a constrained resource envelope. Where governments do procure hearing aids or cover them through an insurance scheme, suppliers have faced long sales cycles, late payments, and government reimbursement rates that are too low to cover costs, which limits their desire to interact with government as a customer (refer to Case Study 4).

While prices for hearing aids are often prohibitive to L.M.I.C. buyers, manufacturers are reluctant to reduce rates due to concerns about price erosion. The above-mentioned challenges, in combination with a H.I.C. market that is not yet saturated (e.g. H.I.C. market has ~20% market penetration), lead to companies focusing on high-value markets. New generation products are launched every 3 years and are the main driver of market value growth. In the absence of public spending and given the constrained size of the private market in most contexts, N.G.O.s and C.S.R. initiatives are sometimes the only hearing aid provision occurring within a country.