TO ACCELERATE ACCESS to assistive technology (AT), it is critical to leverage the capabilities and resources of the public, private, and non-profit sectors to harness innovation and break down barriers to affordability and availability. Market shaping interventions can play a role in enhancing market efficiencies, as well as coordinating and incentivising the number of stakeholders involved in demand and supply-side activities. Across health areas, market shaping has demonstrated its potential to enhance national governments' and donors' value-for-money, diversify the supply base, and increase reliability – ultimately increasing product and service delivery access for end users. ATscale, the Global Partnership for AT, aims to apply market shaping approaches to AT, mobilising global stakeholders in line with a unified strategy. To inform this strategy, a comprehensive analysis of the entire value chain, followed by a plan to coordinate interventions on the supply and demand side, is required to address how the market is organised and to overcome barriers to access. The first product undergoing analysis by ATscale is wheelchairs.
Globally more than 75 million people need an appropriate wheelchair, however 85-95% of those in need do not have access. Four in five people who need a wheelchair live in low- and middle-income countries (LMIC) 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, this number is likely closer to 5% in LMICs.
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. The use of an appropriate wheelchair enhances users' personal mobility, which is a precondition for active participation in education, employment and civic life.
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. The WHO Guidelines for the Provision of Manual Wheelchairs in Less Resourced Settings emphasise eight steps for appropriate wheelchair service to assist stakeholders in developing appropriate wheelchair provision systems in different country contexts. Product standards and specifications for wheelchairs in low resource settings have been developed, or are in development, but uptake to guide purchasing and design has been limited.
The global market for wheelchairs, US$4.0-4.5 billion in 2018, primarily focuses on high-income markets and is largely fragmented. The United States and Western Europe account for about 40% and 20% of the market, respectively. The five largest manufacturers control less than 50% of the global mobility market.
The primary global manufacturers do not focus on LMICs, as there is limited public funding for procurement and provision of wheelchairs in LMICs; where procurement within the public sector exists, it is often fragmented and/or erratic. NGOs have filled the gap to design, produce and provide wheelchairs that are appropriate for use in low resource settings. Charitable organisations that donate product dominate funded wheelchair demand in LMICs.
Enabled by favourable government policies, incentives to manufacture locally, and the perception that wheelchairs are a low-tech product, several local manufacturers exist in LMICs. Their wheelchairs are designed for the local context, but the manufacturing process is often labour-intensive, expensive to initiate and requires materials or parts from abroad, which limits the ability to scale. While not heavily utilised in LMICs at the moment, localised assembly of component parts could support a cost-effective supply of appropriate wheelchairs. Generic suppliers that serve as contract manufacturers for NGOs and FBOs to produce quality wheelchairs may also be able to supply LMICs cost-effectively, but lack market visibility or scale.
LMIC markets for wheelchairs are nascent, with a need to focus on demand creation. The demand and supply dynamics that have challenged the development of a wheelchair market include: limited awareness of need; limited government involvement; fragmented finance, procurement and provision landscapes across numerous NGOs, FBOs and government; lack of service provision; lack of quality standards and preferred product profiles to support tendering; limited market visibility and incentives for global suppliers to enter LMIC markets; and low use of cost-effective supply mechanisms.
To overcome these market challenges, a multi-pronged approach that is informed by a long-term vision towards a sustainable market for appropriate wheelchairs and their provision in LMICs is required. Four proposed strategic objectives to achieve this include:
These strategic objectives are supplemented by initial activities to support access to affordable, quality, and appropriate wheelchairs and related services. ATscale is currently in the process of developing a prioritisation process to inform which of the market shaping activities proposed in this document will be incorporated into the Partnership's initial action and investment plan to guide activities and investment in the short-term. While that is underway, some of these proposed activities will be undertaken in the immediate term by the AT2030 programme, funded by UK aid, in line with its aim to test what works to increase access to affordable AT.