3. Market Context

3.1. Globally more than 75 million people need an appropriate wheelchair, however 85-95% of those in need do not have access.

Wheelchairs are one of the most commonly used assistive devices; WHO estimates that 1% of the population, approximately 75 million people globally, require a wheelchair.3 Those needing wheelchairs are those with mobility limitations and may include people born with congenital abnormalities, people with developmental and neurological conditions, such as cerebral palsy or muscular dystrophy, people with a spinal cord injury, people with musculoskeletal conditions such as lower limb amputation, people living with physical impairment which can be a result of polio or non-communicable diseases (NCDs) such as diabetes or stroke, and older people with gradual functional decline.

Four in five people who need a wheelchair live in LMICs,4 and these countries account for the highest unmet need. While 90% of people with a need in high-income countries (HIC) are estimated to have a wheelchair,5 this number is likely closer to 5% in LMICs. It is estimated that 64 million people need a wheelchair in LMICs (Table 1). This represents a crude estimate of need due to the lack of data available.

TABLE 1: MARKET SIZING FOR WHEELCHAIR NEED

WHO REGION	WHEELCHAIR NEED (IN MILLIONS)	ESTIMATED WHEELCHAIR COVERAGE (IN PERCENTAGE)	UNMET NEED (IN MILLIONS)
Americas (excluding HICs)	~6	5%	~6
Europe (excluding HICs)	~4	5%	~4
Africa	~10	5%	~10
South-East Asia	~26	5%	~25
Western Pacific	~20	5%	~19
HICs	~9	90%	~1
Global	~75		~65

The need for wheelchairs will only continue to grow globally, especially in LMICs. A growing need is driven by:

• AGING: world's population over 60 years of age is expected to double to 2 billion between 2015 and 2050;6
• INCREASING RATES OF INJURY: increasing rates of road traffic injury, occupational injury, violence and humanitarian crisis contribute to the high and growing rate of disability in LMIC; for example, although the rate of disability-adjusted life year (DALY) from road injury is decreasing in high-income countries, the rate has increased in South Asia (6.5%), West sub-Saharan Africa (13.1%) and South sub-Saharan Africa (32.5%) from 1990 - 2013. In the same period, DALYs attributed to interpersonal violence in South sub-Saharan Africa and Oceania have increased 50%.7
• GROWING BURDEN OF NCDS: stroke prevalence has increased 14% annually8 in low-income countries over the past three decades and the number of people with diabetes is expected to rise to 552 million in 2030 from 336 million in 2011 with greatest rate of increase (92%) occurring in low-income countries.9

3.2. Access to an appropriate wheelchair is critical to increasing civic and economic engagement and preventing negative health outcomes

An appropriate wheelchair is defined as one that: meets the user's needs and environmental conditions; provides proper fit and postural support; is safe and durable; is available in the country; and can be obtained and maintained and services sustained in the country at an affordable cost.10 The use of an appropriate wheelchair enhances users' personal mobility, which is a precondition for active participation in education, employment and civic life.

Being properly fitted with an appropriate wheelchair is critical to a user's health and quality of life. Proper fitting helps prevent various secondary health conditions such as: pressure sores and progression of postural deformities or contractures; respiration and digestion complications; and, in cases of people with spinal cord injuries and similar conditions, premature death.11 A study from Sri Lanka showed that 75% of people with spinal cord injuries admitted to hospital died within 18-24 months from secondary complication because of their injuries; however, when healthcare training and appropriate equipment provision improved – including appropriate wheelchairs with cushions – the incidence of pressure sores reduced by 71% and repetitive urinary tract infection decreased by 61% within two years.12

3.3. Appropriate wheelchair service, provided by trained personnel, plays a critical role in matching the user's needs to the appropriate type of wheelchairs needed throughout the user's lifespan.

WHO categorises wheelchairs as follows:

• WHEELCHAIRS DESIGNED FOR TEMPORARY USE.14 Typically called depot, transport, orthopaedic or “hospital” wheelchairs, this type of wheelchair is designed for temporary use and does not provide the user with additional fitting, postural support or pressure relief. It is frequently pushed by an attendant or carer.

• WHEELCHAIRS DESIGNED FOR LONG-TERM USE. Sometimes called active wheelchairs, they are designed for long-term use, are adjustable to ensure proper fit, provide pressure relief, and typically provide basic postural support needs (additional postural support devices may be added to fit user needs):

  • Based on the means of propulsion, active wheelchairs can be divided into manual and powered wheelchairs. Manual wheelchairs are self-propelled or attendant propelled.

  • Based on the environment the wheelchair is primarily used in, active wheelchairs can be divided into:

    • Indoor/urban/even-surface wheelchairs: typically lightweight, can have a fixed/rigid or foldable frame, transportable and easy to manoeuvre in small spaces;
    • Outdoor/rural/rough-terrain wheelchair: designed to be robust, more stable, and easier to propel over uneven ground. They often have three wheels and a much longer wheelbase;
    • Dual-use/indoor-outdoor wheelchairs: have some level of compromise for both environments; for example, a robust wheelchair with large castor wheels, but with a short wheelbase.
• WHEELCHAIRS WITH POSTURAL SUPPORT. This type of wheelchair is designed for users requiring a higher degree of postural support such as users with significant muscle weakness or people with cerebral palsy. These wheelchairs are typically highly adjustable, modifiable and come with additional postural support systems such as back support, head support and a positioning cushion. The seating system can be added to a long-term use wheelchair, although more adjustable wheelchair systems are also used.

TABLE 2: EXAMPLES OF WHEELCHAIRS FROM EACH CATEGORY AND INDICATIVE PRICING 15

TEMPORARY USE	INDOOR/URBAN/ EVEN-SURFACE	OUTDOOR/RURAL/ ROUGH-TERRAIN	DUAL USE/ INDOOR-OUTDOOR	POSTURAL SUPPORT
LMICs: ~US$80 HICs: US$100-800	LMICs: US$150-300 HICs: US$2,100-3,500	LMICs: US$150-300 HIC: rarely found	LMICs: US$200-300 HIC: rarely found	LMICs: US$180-350 HIC: US$2,200-4,000

PHOTOS USED WITH PERMISSION FROM CLASP.ORG

A wheelchair should be provided based on an assessment of the user's physical abilities, lifestyle and environment (Figure 2). The wheelchair service then fits a wheelchair to the user, adjusting the features to ensure maximal functions are possible whilst ensuring the safety of the user. The wheelchair user and their caregiver (where applicable) are trained on how to safely and effectively use and maintain the wheelchair. The wheelchair service provides follow-up, maintenance and repair services for the product.

FIGURE 2: FACTORS AFFECTING CHOICE OF WHEELCHAIR (LEFT) AND COMMON ADJUSTMENTS TYPICALLY MADE ON MANUAL ACTIVE OUTDOOR/RURAL/ROUGH-TERRAIN WHEELCHAIRS (RIGHT)

FACTORS AFFECTING WHEELCHAIR SELECTION

Need of mobility aids	Short duration/ intermittent Long-term/permanent
Ability to propel	Low (requires attendant/powered) Medium (e.g., one hand) High
Physical size	Paediatric/Adult Width, length, and height variations
Living & working environment	Outdoor/rough terrain Indoor/even surface/ urban setting Mixed (indoor and outdoor)
Risk of developing pressure sores	Low Medium High (e.g., people with spinal cord injury)
Postural support needs	Basic Intermediate Advanced

EXAMPLES: ACTIVE, MANUAL, ROUGH-TERRAIN WHEELCHAIR

• Frame

  • Usually fixed frame; 3 or 4-wheel frame format
  • Long wheelbase (longer than dual terrain wheelchair)
  • Large overall length and large turning circle
  • Ergonomically placed push handles for controlled assistance
  • Integrated stability options for feet
  • Dirt protection
  • Low centre of gravity compared to other active wheelchairs

• Center of Gravity: Frame Adjustments

  • Rear wheel horizontal adjustability/ custom options
  • Front castor optional horizontal adjustment

• Frame-Size Range

  • Size width range to be appropriate for the population profile and include paediatric, adult and bariatric sizes as appropriate
  • Size range in 1-1.5” (25 - 40mm) increments
  • Range of seat depth options

• Wheels and Castors

  • Minimum 3 degrees of camber on rear wheels
  • Larger diameter of push rim ring
  • Larger rear wheel size; Wider or larger tread tires
  • Wider (minimum 2”/50mm) and larger diameter (more than 8”/200mm) castor wheels

3.4. Common guidelines exist to ensure the provision of appropriate wheelchairs in less resourced settings

Many wheelchair users in less resourced settings (LRS) receive wheelchairs without the appropriate related service. As a result, users often receive wheelchairs that are inappropriate for their needs, ill-fitting and provided without training on how to safely and effectively use their wheelchair.

In light of contextual realities, a consensus-driven process supported the development of the WHO Guidelines for the Provision of Manual Wheelchairs in Less Resourced Settings. The WHO Guidelines emphasise eight steps for appropriate wheelchair service (known as the WHO 8-Steps – see Figure 3) to assist stakeholders in developing an appropriate wheelchair provision system in different country contexts.16 Following the release of the Guidelines in 2008, WHO developed the Wheelchair Service Training Package (WSTP) to support training.

The WSTP consist of:

• WSTP-BASIC LEVEL AND TRAINING OF TRAINERS: To develop the minimum skills and knowledge required by personnel involved in wheelchair service delivery.17
• WSTP-INTERMEDIATE LEVEL AND TRAINING OF TRAINERS: To support the training of personnel to provide an appropriate manual wheelchair and cushion for children and adults who need additional postural support and modification.18
• WSTP FOR MANAGERS AND STAKEHOLDERS AND TRAINING OF TRAINERS: To inform managers and stakeholders about the importance and benefit of proper wheelchair service provision which is necessary in order to develop effective and sustainable wheelchair service provision.19

The Guidelines have been adopted by various NGOs and large charitable organisations to improve their delivery process and product design to be more in line with best practice. Uptake by country governments has been low due to lack of awareness of the WHO Guidelines, a lack of existing service provision systems for wheelchairs or AT, and limited donor support for the dissemination and adoption of the Guidelines worldwide.

3.5. USAID has been the primary bilateral funder addressing wheelchair needs in LMICs

To address the unmet need for wheelchairs in LMICs, USAID and other US government agencies have collectively invested more than US$70 million over the past ten-plus years. USAID's commitment to wheelchair provision is significant within the sector, but this amount represents a fraction of the spending required globally per year. Other bilateral funders, such as Australia's Department of Foreign Affairs and Aid, UK's Department for International Development and the Swiss Agency for International Development, have funded or fund wheelchairs or wheelchair provision, often through one-time grants.

In 2007, USAID established the Wheelchair Program to improve access to appropriate wheelchairs and trained service providers in developing countries. The Program has evolved from direct procurement of wheelchairs to supporting investments that would result in systemic and sustainable improvement for the sector. In order to achieve this, USAID has focused their investments in the following key areas: 1) policies to improve access to appropriate wheelchairs and quality services are developed and implemented; 2) access to quality, sustainable services improved; 3) professional standards clearly defined and adopted; and 4) appropriate products are more readily accessible.

Programmatic investments have included both country-based initiatives and global initiatives. A few examples of investments include an Indonesian programme to integrate wheelchair service into the healthcare system, a multicounty programme in partnership with World Vision to support appropriate delivery of wheelchairs in five countries and a Georgian programme to establish wheelchair production and provision. Examples of research funding include assessing influence of peer-group training for active wheelchair users in Romania and studying the impact of service on wheelchair usage in Kenya and the Philippines.

Examples of USAID global investments include:

• CONSOLIDATING LOGISTICS FOR ASSISTIVE TECHNOLOGY SUPPLY AND PROVISION (CLASP). CLASP is a centralised distribution hub launched in 2014 as a solution to supply-side challenges faced by wheelchair service providers in LRS including limited product variety, variable quality, extensive lead-time, and logistical burdens.20 [Section 4.12. describes CLASP in more detail]
• INTERNATIONAL SOCIETY OF WHEELCHAIR PROFESSIONALS (ISWP). Launched in 2015, ISWP serves as a global resource for wheelchair service standards and provision through advocacy, education, standards, evidence-based practice, innovation, and a platform for information exchange. Some of its outputs include: Basic wheelchair knowledge test; Wheelchair hybrid course, Seating and Mobility Academic Resource Toolkit; a training management platform for the wheelchair sector; and a product catalogue and product standards to promote quality and appropriate wheelchairs.21
• GLOBAL COOPERATION ON ASSISTIVE TECHNOLOGIES (GATE). Led by the World Health Organization GATE is a global initiative to realise the obligations of the UN Convention on the Rights of Persons with Disabilities (CRPD) towards increasing access to assistive technology. Some of GATE'S achievements include the development of the priority Assistive Products List (APL), the adoption of a Resolution on “Improving access to AT” at the 2018 World Health Assembly and the creation of training modules for primary healthcare workers to safely and effectively provide priority AT.