There exists a lack of awareness around the need for and importance of appropriate wheelchairs among end-users, service providers and policymakers.

At the policy level: Policymakers lack awareness and data on the need, importance, and impact of appropriate wheelchairs for users and society. This affects prioritisation in policy, programmatic, personnel's training, and financing decisions. Adoption of the WHO Guidelines on wheelchair provision for LRS has been limited at the country level and mostly driven by NGOs.

At the provider level: Wheelchair service provision and training on seating and positioning is often not seen as part of the scope of practice for relevant professionals such as physical therapists, occupational therapists, orthotists and prosthetists. Training packages, such as the WSTP, have not been adopted in training curriculums or by professional associations.

At the user level: Most wheelchair users in LMICs are marginalised members of the community who are not empowered with knowledge on appropriate wheelchairs. When users do not understand the importance of an appropriate wheelchair or do not know that multiple types exist, they will prioritise the lowest cost option or accept an inappropriate wheelchair delivered through mass-distribution.

Among the public: The public can stigmatise a person for using a wheelchair, this can prevent or limit use. Furthermore, the buildings, transport systems and large parts of the built environment remain inaccessible to wheelchair users, meaning they are excluded or take undue risks (e.g. wheeling on busy roads).

Government involvement is low. Donor funding that fills this gap and supports ‘free’ product inhibits the development of a public market.

Only recently have many LMICs developed national policies for people with disabilities, so the implementation has not reached optimal levels.

Low prioritisation from governments results in limited to no financing for the purchasing and provision of appropriate wheelchairs. Where funding is available, the amount is low and often divided across different Ministries, with lack of coordination. There is little investment by government to set up the systems and train providers.

Charitable organizations, supported by independent donations, drive the funded demand in LMICs. The donor landscape is concentrated around two FBOs, followed by multiple NGOs providing wheelchairs through a variety of access points in local communities. These organisations emerged to fill gaps not being met by government; however, key informant interviews suggest that delivery by these actors has inhibited government engagement, possibly due to government perception that other organizations are meeting user needs and therefore there is not a role for government to play.

The capacity for service provision in line with the WHO Guidelines is limited.

Due to a lack of awareness, prioritisation and investment in this sector, even donated products are often not provided through a wheelchair service, resulting in a lack of users being appropriately assessed and fitted. Countries lack providers that are trained in line with the WSTP. Misconceptions that providing the product is sufficient and desire to ‘do good’ leads to mass-distributions of wheelchairs where no user-assessment and fitting by trained personnel are conducted and no follow-up or maintenance is available. Where trained providers exist, they are concentrated in a few urban areas or in specialised or NGO hospitals that are inaccessible or unknown to users.

Countries and providers often lack the willingness to invest in more comprehensive training modules, particularly for fitting more users with more complex seating needs. Experience suggests that once people start participating in training and see the value of appropriate fitting and difference it can make, then they demand more training to meet more users' needs. Getting sufficient training funded at the outset is often very hard for the reasons mentioned above. Currently, funding is overly invested in the purchase of wheelchairs, with limited amounts invested in training for proper provision, even though the per unit training costs are minimal.

There is a lack of financing - both public and private - for the purchase of appropriate wheelchairs.

Governments lack policies or insurance schemes that allocate funds for wheelchair procurement and provision. When funds are available, they are insufficient and therefore governments look to purchase the cheapest products that they are aware of, which are often of low quality. Frequently, transport-type wheelchairs for temporary users rather than wheelchairs appropriate for long-term users are purchased. Lower quality chairs have a short life span and can increase long-term costs to the public system.

For many people who need a wheelchair, even low-cost wheelchairs are priced above the ability to pay, so out-of-pocket payments are limited or non-existent, especially among the poorest.

Small user contributions have been used by some NGOs to gain user buy-in to the maintenance of the product and to increase user engagement. There is limited evidence if user contributions reduce abandonment or breakdown rates.

Limited consensus on a range of preferred product classes and no commonly accepted objective measure of what is an appropriate wheelchair has contributed to a proliferation of products.

Different interpretations exist among global stakeholders about the minimum quality standards for wheelchairs in LRS environments that ensure products are robust and durable. Some organisations have developed tools to assess quality, but acceptance and adoption is limited.

In addition to a lack of consensus on quality standards, NGOs and FBOs have designed and manufactured their own range of products, which contributed to fragmentation in financing, procurement and product design. FBOs have significant buying power, but the focus on controlling costs has led to these organisations designing their own product range rather than buying existing products. Many NGOs on the other hand often operate a social enterprise model where revenues from wheelchair sales are an important income stream to sustain other programmes.

Limited feedback loop from end-users to inform product design and innovation.

The initial focus to design and develop wheelchairs that are lower cost and more robust in LRS has led to products that are typically heavier and less portable compared to HIC markets. Both the portability as well as the style are deemed important by users to reduce stigma, which points to a lack of user-centred design.

Research is ongoing to look at the issue, but this research is often not initiated by or in collaboration with the manufacturers and their research and development teams. One of the best ways to obtain feedback from users is to have a presence in the field, which has supported the dual role of supplier and service provider used by Motivation or UCP Wheels. However, these NGOs have difficulties finding and accessing early-stage investment for product R&D to bring new or improved products to market. Distribution hubs may be able to pool user feedback from disparate environments and buyers for suppliers.

Manufacturing economics for current appropriate products are unfavourable.

Small volumes and wide range of SKUs lead to inefficient manufacturing schedules and increased production costs. Annual volumes from NGOs and FBOs are low, with the exception of FWM and LDS Charities. Low volumes lead to higher raw material costs and a higher number of changeovers on production lines, increasing downtime. Low volumes also limit the investment case for: 1) lines with a higher capacity and lower incremental capital investment per unit produced; and 2) the automation of certain production steps in order to increase throughput.

Demand is commonly driven by donor purchasing, with erratic procurement patterns. Similarly, some governments tend to buy in cycles. Because wheelchairs are costly and relatively bulky products to store, suppliers need a high amount of working capital to hold a good stock level and suppliers will mostly produce to order, which complicates the workforce and production planning.

Leading global manufacturers have limited interest in entering LMIC markets.

Leading global manufacturers, such as Invacare or Sunrise, do not invest in products and systems to supply LMIC markets because they don't see the pathway to profitability. As a result, these companies are trying to fit HIC models and approaches into an LMIC context. This includes a bespoke production model and the need to work with distributors that provide customisation support. Such approaches further increase cost in markets where there is limited ability to pay and opportunity for value creation.

Governments have a preference for locally manufactured products.

Governments perceive wheelchairs as relatively simple to manufacture and a good case to create employment opportunities for people with disabilities. However, the market shows that due to limited demand, many local manufacturers struggle to reach scale to produce cost-effectively and competitively. Due to the relatively high capital expenditure required to set up a level of automation and/or working quality control systems, local manufacturers are often smaller, artisan workshops, producing lower quality products than what could be sourced elsewhere.

Limited use of cost-effective supply mechanisms.

Most wheelchairs are manufactured in China and shipping costs are high. CLASP has been designed to reduce transaction costs while making supply more efficient and appropriate. Uptake has been limited for the variety of reasons outlined above, including that it is often less expensive to procure directly from the manufacturer.

High import taxes increase price to the final payer.

High import taxes for raw materials and parts increases the cost of local manufacturing making local products less competitive than assembled, imported products, which often benefit from tax breaks or exemptions. High import taxes on spare parts also hinders the ability to have spare parts for maintenance available.

Limited quality assurance mechanisms at the demand and supply side.

Demand: Where countries have funding, they select low quality, cheaper products that do not meet the needs of users. Quality standards and product specifications for what constitutes appropriate product and provision are not in place. When government puts out a tender for wheelchairs, often the only information they have is price.

Supply: Due to the lack of regulation around quality assurance in many LMICs the quality assurance approaches from suppliers into LMIC markets is effectively voluntary and often driven by the business philosophy of the supplier. Quality assurance is an added cost, therefore many suppliers will not undertake testing if not paid for or necessitated by regulation. In contrast NGOs' suppliers, will generally necessitate quality testing – due to funder requirements and restrictions, – which adds cost to their product. Therefore NGO wheelchairs are less attractive to LMIC governments than contracting directly with - for example - a standard Chinese supplier whose quality may be substandard.

Fragmented funding drives fragmented procurement and limits reach.

Fragmentation across the NGO and public sector limits the ability to aggregate demand and incentivise volume- and value-based procurement. It contributes to a lack of visibility and data on actual demand. In many cases, the presence of a charity model masks the actual demand for appropriate wheelchairs.

NGO sector: FBOs, NGOs and CSOs, such as Lion's Club or Rotary Club, consolidate monetary and product donations to then be provided to the community that they work in. Products are often distributed at different levels with little to no coordination, which leads to unequal distribution of the limited resources that are available. For example, one community could receive wheelchairs multiple times a year from campaigns, while other localities are never reached.

Public sector: Where a public payer does exist in LMICs, funding is fragmented across ministries or difficult to access. Ministries may not routinely budget for wheelchairs and often submit orders or accept donations in an ad-hoc manner. Limited record keeping and visibility on who has previously received products leads to some end users receiving multiple wheelchairs and others who are never reached.

Procurement is often not linked to service delivery so inappropriate product types are selected. This contributes to an inability to forecast for a mix of appropriate products.

There is limited to no data on unmet need and funded demand for appropriate wheelchairs in LMICs.

Buyers: lack understanding of available and quality suppliers and their product offerings. Purchasers are unable to make informed choices when navigating a highly fragmented, unorganised market of suppliers with a vast product mix. Frequently products can be received but are then not used as they are not fit for purpose leading to further invisibility of the market.

Suppliers: lack of demand information such as visibility to government tenders and capacity to respond to government tenders that do exist limits investment in production capacity and allocation of capacity for appropriate products thus increasing transaction costs.