Abstract
The ISPO Consensus Conference on Wheelchairs for Developing Countries was held in collaboration with Leahy War Victims Fund of the United States Agency for International Development (LWVF-USAID) and the World Health Organisation (WHO) at Mobility India, Bengalooru (Bangalore), India from 6th – 11thNovember, 2006. The report of the meeting, edited by Sarah Sheldon and Norman A Jacobs, will shortly be published by ISPO. The conclusions and recommendations from the conference follow below. These were the result of extensive discussion in syndicate and plenary sessions. Summaries of these discussions as well as the supporting presentations can be found in the published report.
Wheelchair
Purpose of a wheelchair
The fundamental purpose of a wheelchair is to promote mobility, inclusion and enhanced quality of life of the user.
Definition of a wheelchair
An assistive device which enhances personal mobility and facilitates participation, for a person with walking limitation (WHO definition). A technical aid intended to provide wheeled mobility and body support for individuals with impaired mobility to walk (ISO 7176 – 26: Wheelchairs – Vocabulary, FDIS 2005). A device to provide wheeled mobility with a seating support system for a person with a walking limitation (ISO definition modified by the conference). It is recommended that ISO revise its definition of a wheelchair in order to take account of the currently accepted terminology.
Definition of an appropriate wheelchair
A wheelchair is appropriate when it meets the individual's needs and environmental conditions; provides proper fit and postural support based on sound biomechanical principles; is safe and durable; is available and can be accessed, maintained and sustained in the country at the most economical and affordable price.
User involvement
“It is about the user, not just about the wheelchair”. Wheelchair users should be involved in all aspects of wheelchair provision.
Needs
Needs assessment
According to WHO it is estimated that about 10% of the population are people with disabilities. Studies also show that about 10% of people with a disability require a wheelchair. There is no accurate figure for the number of people in developing countries that require a wheelchair. It is estimated that about 1% in any given population, i.e. about 65 million people worldwide require a wheelchair. Anecdotal evidence indicates a very small minority of those in need have access to an appropriate wheelchair. More accurate data of the needs are required to be collected in order to be able to address them. It is important to develop and implement standardized tools and methodology for data collection. The number of people who need wheelchairs is so large that all efforts should contribute towards developing long-term sustainable services.
Outcome measures
Reliable record keeping is essential for all phases of wheelchair provision including assessment, prescription, fitting, delivery and follow-up. Regular follow-up/evaluation of outcomes of wheelchair provision should be performed. User satisfaction surveys must be an integral part of outcome assessment. User satisfaction surveys should be performed and include measures of the impact of wheelchair provision on the quality of life of the user.
Information sharing
There is a lack of shared information about resources, activities and initiatives which may result in a duplication of efforts and gaps in services. The establishment of a website and/or an accessible database would be of benefit to those involved in wheelchair provision.
Services
(Note: in this document Wheelchair Services refers the service delivery of wheelchairs to the individual users. Wheelchair Provision refers to the overall subject including design, manufacture distribution and services)
Wheelchair services are an integral part of wheelchair provision. User participation is an integral part of wheelchair services. Wheelchair services should be delivered by trained personnel. Government has the primary responsibility for sustainable wheelchair service. Wheelchair services should be an integral part of national strategies. The wheelchair services are encouraged to ensure that people with disabilities from all sectors of society are provided with appropriate wheelchairs including those from marginalised and vulnerable groups such as women and children. The aim of wheelchair services is to ensure that the person in need of a wheelchair receives it together with the necessary information and support. The wheelchair should meet the individual's needs in terms of mobility, appropriate fit, comfort, safety and ability to carry out activities of daily living and exercise basic human rights. The following table was agreed as a first draft of specifying the elements and requirements for wheelchair services:
Not all elements and requirements are essential, some could be considered as only desirable depending on the context and the socioeconomic conditions that prevail.
Products
As a minimum, developing countries are encouraged to adopt the wheelchair ISO standards as they exist at present, particularly:
ISO 7176-8: Wheelchairs – Requirements and test methods for static, impact and fatigue strengths, 1998 ISO 7176-1: Wheelchairs – Determination of static stability, 1999 ISO 7176-3: Wheelchairs – Determination of the efficiency of brakes, 2003 ISO 7176-5: Wheelchairs – Determination of overall dimensions, mass and turning space, DIS 2005 ISO 7176-15: Wheelchairs – Requirements for information disclosure, documentation and labelling, 1996, and ISO 7176-16: Wheelchairs – Requirements and test methods for resistance to ignition of upholstered parts, 1997. Organisations importing wheelchairs are encouraged to ensure that the wheelchairs meet ISO standards or the wheelchair standards existing in that particular country, whichever is higher. There is a need to develop more demanding versions of ISO standards to represent the more challenging conditions in developing countries. It was recommended that ISO be requested to revise the existing standards to take into account the needs in developing countries. Test methods should be designed to replicate usage in the relevant environments (based on an average life expectancy of 5 years). It was further agreed that there would be value in testing current wheelchair designs. Each of the organizations represented at the consensus conference agreed to participate.
These represent the minimum requirements for wheelchairs provided in these countries.
Production
Standards and guidelines
All wheelchairs, whether locally produced or imported, and whether made in small, medium or large scale enterprises should meet or exceed ISO standards.
User choice
Stakeholders are encouraged to recognise the right of wheelchair users to choose their wheelchair and to work in collaboration with the user. Users' needs are best met when there is a variety of wheelchair models from which to choose.
Acquiring wheelchairs
When determining whether to acquire wheelchairs via import or local production, decision makers are advised to balance a variety of factors. These include needs of the local population, quality and variety of wheelchair models, purchase price, cost of repair and replacement, effect on local employment and wheelchair production, and national policies and strategies including long-term sustainability.
Locally repairable
Regardless of scale and location of production, wheelchairs must be locally repairable.
Distribution
There is a vast need for appropriate wheelchairs in developing countries and it is recognised that there are different methods of wheelchair distribution which are not mutually exclusive but can complement each other. All methods of distribution have a part to play and stakeholders are encouraged to work closely together to ensure that there is no duplication of effort and waste of resources. It is recommended that, irrespective of method of distribution:
the provider has the capacity to provide the wheelchairs in a reasonable and responsible manner; the distribution is based on an assessment of the situation in the country or the region of the country and considers the impact on local wheelchair producers and service providers; procured wheelchairs meet or exceed relevant international standards and be appropriate for the environment of use; wheelchairs are provided following a provision process that meets or exceeds internationally agreed minimum requirements for service provision, including requirements for assessment, fitting, user training and follow-up; wheelchairs are repairable in the region of the country where they are provided or expected to be used; distributors coordinate their distribution with national and local governments as well as producers and providers of wheelchairs in the country; and distributors of wheelchairs network with each other.
Training and education
It is recognized that training and education are key elements for developing, introducing, maintaining and building sustainable wheelchair services. All stakeholders need to be trained and/or informed regarding their roles in wheelchair provision. All individuals involved in wheelchair services should be trained. These may include:
Physiotherapists Occupational Therapists Doctors Nurses Prosthetists and Orthotists Engineers/Technologists/Technicians CBR personnel DPO/Rights group members. In particular the user and assistant must be properly informed and trained. Comprehensive information should be provided to governments, decision makers, donors and other stakeholders. Training and education for stakeholders can be divided into four types:
Formal training to establish specialists in wheelchair provision where possible. Special modules for other individuals involved in wheelchair provision. Comprehensive information for different stakeholders (including government, decision makers and donors). structured/formalized peer training for users and assistants. Professional profiles for specialists in wheelchair provision should be developed. An expert group under the umbrella of an internationally recognized organization should:
develop the professional profiles for the training of people involved in wheelchair service provision. specify the content of the various training, education and information modules required.
WHO guidelines
The importance of developing the WHO Guidelines on the provision of manual wheelchairs in less resourced settings is recognized. In order that the guidelines be effective as soon as possible, it is recommended that WHO quickly incorporate the outcomes from this consensus conference into the guidelines and share a draft of the revised guidelines with a larger audience for review.