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iiiAssistive technology (AT) is an umbrella term covering the systems and services related to the delivery of assistive products such as wheelchairs, eyeglasses, hearing aids, prosthetic devices, and assistive digital devices and software. Today, over 1 billion people require AT to achieve their full potential, but 90% do not have access to the AT that they need. 1 Digital assistive technology (digital AT) is a broad category, but can be defined as assistive products that contain electronic information and communication technologies (ICT). 2 The digital AT ecosystem is made up of four interconnected components that are necessary for people to fully make use of the growing digital services and infrastructure, including: 1) accessible devices (e.g. mobile phones and tablets) and accessories (e.g. switches or braille readers); 2) accessible platforms or operating systems to enable consumption of what is on the device; 3) accessible software and applications that fulfil a particular purpose or user activity; and 4) accessible content, such as text, text-to-speech, native language availability and pictograms. The rate of adoption of the digital AT ecosystem is supported by four cross-cutting enablers: 1) awareness of digital AT and its accessibility by users, developers, suppliers, providers, and policymakers; 2) availability of mobile network and internet connectivity; 3) the application of universal design and inclusion of accessibility features; and 4) appropriate training in digital AT.
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 and/or augment digital assistive technologies. The use of digital AT 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). 3 Moreover, ownership among people with disabilities lags 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 phones as AT; limited disability-inclusive design; and limited use of tools that allow for the full use of mobile phones by persons with disabilities. 4 In order to increase access to mobile phones (particularly smartphones) as AT, there is a need to increase awareness and digital skills training, as well as to improve the affordability of mobile phones and data connectivity in LMICs.
2Screen readers are software programmes for people with vision impairment and/or learning disabilities 5 that convert screen content into an accessible format for the individual, such as braille, speech, or both. Screen readers can be used on laptops, desktop computers, and mobile devices. Different models of screen readers exist: software built into the operating system; open source and free stand-alone software; and commercial paid subscription stand-alone software. Access to screen readers in LMICs is hindered by a number of barriers, including the following: low awareness of the existence and benefits of screen readers; limited availability of screen readers in local languages; lack of training; lack of accessible content; and unaffordable prices for commercial screen readers. In order to increase access to and usability of screen readers, it is proposed to support the development of text-to-speech synthesisers in local languages; establish (sub-)national programmes to enable price agreements with commercial screen reader suppliers; adopt accessibility standards on public government websites and apps; and increase awareness of and training for the use of screen readers.
Assistive technology (AT) is an umbrella term covering the systems and services related to the delivery of assistive products such as wheelchairs, eyeglasses, hearing aids, prosthetic devices, and assistive digital devices and software. Today, over 1 billion people require AT to achieve their full potential, but 90% do not have access to the AT that they need. 6 This unmet need for AT is driven by a lack of awareness of this need, discrimination and stigma, a weak enabling ecosystem, lack of political prioritisation, limited investment, and market barriers on the demand and supply side. Narrowing in on the market shortcomings that limit the availability of assistive products, market shaping is proposed to address the root causes that limit the availability and affordability of and access to appropriate AT, with the wider aim of ensuring improved social, health, and economic outcomes for people who require AT. Increased access to AT is critical to achieve many global commitments, including universal health coverage, the obligations of the United Nations Convention on the Rights of Persons with Disabilities, and the ambitious Sustainable Development Goals. To accelerate access to AT, the global community needs to leverage the capabilities and resources of the public, private, and non-profit sectors to harness innovation and break down market barriers.
Whether by reducing the cost of antiretroviral drugs for HIV by 99% in 10 years, increasing the number of people receiving malaria treatment from 11 million in 2005 to 331 million in 2011, 7 or doubling the number of women receiving contraceptive implants in 4 years while saving donors and governments USD 240 million, 8 market shaping has addressed market barriers at scale. Market-shaping interventions play a role in enhancing market efficiencies, improving information transparency, and coordinating and incentivising the numerous stakeholders involved in both demand- and supply-side activities. Examples of market-shaping interventions include: pooled procurement, de-risking demand, bringing lower cost and high-quality manufacturers into global markets, developing demand forecasts and market intelligence reports, standardising specifications across markets, establishing differential pricing agreements, and improving service delivery and supply chains.
4Figure 1: ENGAGING BOTH DEMAND AND SUPPLY SIDE FOR MARKET SHAPING
Figure showing that demand side engagement and supply side engagement are interlinked.
Work with governments, DPOs, CSOs, and others to:
Digital AT is a broad category, but can be defined as assistive products that contain electronic information and communication technologies (ICT). These products can be organised into two categories: (1) accessible technologies, which refers to products, equipment and systems that have been inclusively designed so as to provide people with disabilities access to all available content within the technology, and can also be used by the general population; and (2) assistive technologies, which refers to specific products, equipment and systems designed to improve function and enhance activities of daily living specifically for people with disabilities. 9 Therefore, built-in speech-to-text applications on smartphones such as Google Live Transcribe are accessible technologies, while dedicated speech-to-text software such as Microsoft’s Adaptive Controller are assistive technologies. 10 The intersection of these two areas is known as Disability Interaction. 11
FIGURE 2: THE DIGITAL AT ECOSYSTEM: COMPONENTS AND ENABLERS
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.
9TABLE 1: TYPES OF MOBILE DEVICES (FROM BASIC TO ADVANCED)
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
10Accessibility 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
11The 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
12The 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.
13ITU 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.
| Rationale | |
| Proposed activities |
Screen readers are software programmes for people with vision impairment and/or learning disabilities that convert screen content into a format that is accessible to the individual, such as braille, speech, or both. 37 Screen readers use text-to-speech synthesiser software that converts the screen elements into speech. A refreshable braille display – a hardware device that displays a braille representation of the text – can additionally be combined with a screen reader to make the digital ecosystem even more accessible. 38
18Globally, estimates show that at least 1 billion people are blind or have a vision impairment. 39 Many are not provided with equal opportunities. For example, in Rwanda in 2012, 56% of working-age people with a severe visual impairment were employed, compared to 71% of the national population, and 41% of those with severe visual impairment had never attended school, compared to 20% of the national population. 40
19TABLE 3 – EXAMPLES OF POPULAR SCREEN READERS BY CATEGORY
20A few years ago, commercial software such as JAWS and SuperNova were the most widely used screen readers worldwide. 45 Open source software like NVDA offered lower quality and fewer features. 46 In recent years, open source screen readers have addressed most of their limitations and are now recognised as being of equal quality in terms of:
A survey run by WebAIM across various regions showed that NVDA became the most common primary computer screen reader in 2018 ahead of JAWS (see Figure 3). 47 This trend is reflected for example in the National Association for the Blind, Delhi moving from JAWS to NVDA as the recommended screen reader five years ago. Users commonly use several screen readers, depending on the type of task they are performing: 73% use more than one screen reader, with 41% using three or more different screen readers. Each screen reader has differentiating features and no all-in-one solution exists.
FIGURE 3 – SHARE OF NVDA, JAWS AND VOICEOVER AS PRIMARY SCREEN READERS OVER TIME, 2009-2019 48
Commercial screen readers remain the preferred choice for many employers as they offer more customisation options and support for specific applications, as reported by WebAIM. 49 For example, if a person with vision impairment is hired by a banking company, JAWS will provide support to customise the screen reader to the banking application, unlike open source screen readers. Some governments have decided to support the employability and employment of people with disabilities by supporting the distribution of commercial screen readers (see Case Study 4).
Accessibility of websites can be measured against a set of international guidelines: the Web Content Accessibility Guidelines version 2.0 (WCAG 2.0). These guidelines provide success criteria and associated requirements to ensure that web-based content can be accessed by people with disabilities. 53 However, these guidelines are not binding unless transposed and enforced by national legislation. The ITU and G3ict Model ICT Accessibility Policy Report and Accessibility Policy Toolkit (e-accessibilitytoolkit.org) provide a model web accessibility policy that governments can adopt. Legislation around web accessibility varies across countries:
Access to print content is also an important issue for people with visual impairment and/or learning disabilities. To tackle this, the Digital Accessible Information System (DAISY) consortium has created technical standards for accessible books. The DAISY standards apply to digital talking books which offer a flexible reading experience for people who are ‘print disabled’, offering a significantly enhanced reading experience. 56 For example, users can search, place bookmarks, navigate line by line, or regulate the speaking speed. 57 Books in DAISY format have been adopted by large accessible libraries such as the Japanese Association of Libraries for the Blind, the US National Library Service for the Blind and Print Disabled, the South African Library for the Blind or the Bibliotheca Alexandrina in Egypt. 58 , 59
Strategic Objective 1: Adopt accessibility standards on public government websites and apps
Strategic Objective 2: Develop text-to-speech synthesisers in local languages
Strategic Objective 4: Train people with disabilities in digital AT
| Rationale | |
| Proposed Interventions |
Common conditions that can lead to communication impairments include amyotrophic lateral sclerosis (ALS), Alzheimer’s disease, Parkinson’s disease, autism spectrum disorders, stroke, brain or head injuries, or cerebral palsy. 60 People with other lifelong, acquired or progressive conditions may also have or develop expressive and/or receptive communication impairments in parallel. For example, rural rehabilitation
27services across Pakistan, Uganda, and Zimbabwe identified that 38-49% of individuals with other primary disabilities also had some form of communication impairment. 61
Both younger and older people face communication limitations. Children as young as 12 months old with little or no speech capabilities often benefit from early AAC intervention. Providing AAC to younger children can prevent learning delays, strengthen understanding of language and future communication ability, and allow for wider participation in school. 62 As children age, their AAC needs will most likely evolve. Adults who develop communication impairments later in life as a result of disease or injury will require different types of AAC as many may have previously had natural speech capabilities. Adults who use AAC may also experience changing communication needs, especially if they have progressive conditions that increase the severity of their communication impairment over time.
Approximations vary on the number of people who require AAC. Estimates in the UK suggest that 0.5% of the population struggle with daily communication and would benefit from AAC. 63 Applying the same prevalence as in the UK would indicate a global need of around 40 million people. 64 However, the number and types of people requiring AAC in LMICs may be different as they generally have younger populations. The number of people with communication needs will continue to grow, especially in LMICs, driven by growing populations and increasing awareness of common communication impairments like aphasia (a communication limitation that impacts people after stroke or brain injury) or those associated with autism spectrum disorders or neurodiversity. 65
Aided systems range from low-tech to high-tech products. Low-tech products are paper-based, while high-tech products are electronically powered systems. 66 These products can be accessed through an array of motions. The four primary access methods for aided AAC systems are touch, mouse/mouse alternatives (e.g. joystick), eye gaze, and switches. Table 4 illustrates a range of methods to enable a person to access boards, charts, books, computers, etc. on which there will be text or symbols that the person is communicating. This may involve the use of speech output when using computer-based devices.
28TABLE 4 – EXAMPLES OF COMMON AIDED AAC SYSTEMS
Paper-based / low-tech AAC examples
29Electronic / high-tech AAC examples
30In 2017, global AAC revenue was USD 168.6 million, 67 with a 70% combined market share in Europe and North America. 68 Asia-Pacific made up 18%, while Latin America and Africa had 9% and 3% of market share respectively. 69 Higher demand for AAC in the US and Europe is predominantly driven by access to funding. As a result, the five largest AAC suppliers (Abilia, Mayer-Johnson, PRC-Saltillo, Zygo, and Tobii Dyanox) can also be found in those regions. These suppliers tend to focus on product innovation and continuously release new high-tech devices.
Awareness of the benefits of AAC is low in LMICs for several reasons. Data about communication impairments is not systematically captured in LMICs and therefore the need for AAC may not be fully understood. Identifying communication impairments can also be challenging in LMICs because there is a general shortage of experts capable of diagnosing and recommending AAC solutions. For example, there is one speech language pathologist (SLP) for every 3 million people in Sub-Saharan Africa, compared to one SLP for every 3,250 people in the US and UK. 72 Furthermore, SLPs in LMICs are typically concentrated in urban areas, which can result in neglect of rural communities.
Medical professionals, including SLPs, often also have limited training in the benefits of AAC. In HICs, some organisations and governments have created tools to help build awareness and learning for medical professionals. For example, the NHS Education for Scotland developed IPAACKS (informing and profiling AAC knowledge and skills) as a resource to support the learning and development of people working with individuals who use AAC. 73 However, these types of resources are lacking in LMICs.
32Freely available culturally appropriate symbol sets were created to overcome some of these challenges. For example, Global Symbols is an open source project that was started in 2016 in order to create an online database of high-quality symbols for different cultural contexts. 74 Initiatives like Global Symbols are helping to expand AAC access to LMICs, especially in countries without localised AAC content.
Research in the US indicates that roughly one-third of AAC systems will be abandoned by users, often due to lack of support and training. 77 Ongoing support and training, both for the user and their support network (e.g. parents, teachers, and colleagues), are essential to avoiding product abandonment. Formal training programmes, online communities, and informal channels all help people learn how to effectively use and integrate AAC products into their daily lives. Routine evaluation is also necessary to ensure an AAC system continues to meet a person’s communication needs. For instance, people with ALS may have evolving communication needs as their condition changes. Loaning devices to people and replacing them once their needs change has proven to be an effective model. For example, the UK has saved taxpayer funds by reissuing almost 40% of nationally procured AAC devices. However, follow up after product provision is often neglected in LMICs due to budget constraints, limited professional expertise, and distribution complexity. This can result in even higher abandonment rates for AAC systems in LMICs.
Strategic Objective 3: Test and validate AAC solutions for low resource settings
| Rationale | |
| Activities |
Strategic Objective 4: Ensure availability of free and effective AAC applications
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THIS REPORT WAS DELIVERED UNDER THE AT2030 PROGRAMME, FUNDED BY UK AID.
