Abstract
Scope
This article examines the structural and institutional factors contributing to the high cost of assistive products within the Portuguese Service Delivery Model between 2011 and 2022. It situates the Portuguese framework within a broader European context through a comparative analysis with Spain, Italy, and Ireland, aiming to identify operational inefficiencies that hinder the universalisation of access.
Method
The study employs a longitudinal analysis of national budgetary data and beneficiary trends, complemented by a comparative review of international service delivery models. To evaluate long-term sustainability, expenditure projections for 2035 and 2050 were calculated using the 2022 executed expenditure as a baseline, applying a Compound Annual Growth Rate (CAGR) of 3.43% derived from historical trends. The research evaluates the relationship between public R&D investment, market competition, and end-user affordability through the ‘entrepreneurial state’ framework.
Key Findings
The study identifies ‘financial paradox’: while total executed expenditure nearly quadrupled (from €9.9M to €37.7M) between 2011 and 2022, the total number of people supported declined by 22% (from 24,511 to 19,123 individuals), resulting in a nearly fivefold increase in the average cost per beneficiary. This trajectory indicates that the ecosystem has shifted towards a ‘value-based pricing’ logic, mirroring the pharmaceutical industry’s strategy of setting prices according to the state’s maximum fiscal capacity rather than actual production expenditure, leading to a ‘double charging’ of taxpayers where public funds de-risk the market without ensuring equitable returns. To address this, the findings advocate for a structural policy adjustment that includes integrating social conditionalities into R&D funding, promoting mass customisation and open-source distributed manufacturing to decouple autonomy from market-driven price rigidity, and reducing regulatory barriers to reposition assistive products as essential public infrastructures rather than niche commodities.
Introduction
The provision of assistive products (APs) is increasingly marked by a systemic tension: while technological progress promises lower manufacturing costs, public expenditure continues to surge alongside stagnant or declining coverage. Evidence from adjacent sectors, particularly pharmaceuticals, indicates that prices often reflect ‘value-based pricing’ strategies – where costs are set according to the maximum fiscal capacity of public systems and the perceived ‘value’ of human autonomy – rather than actual production or R&D expenditure.1,2
In the Portuguese context, this has created a ‘financial paradox’. Between 2011 and 2022, the state experienced a 22% contraction in the number of citizens effectively supported, yet the budgetary execution for these products quadrupled. By applying the ‘entrepreneurial state’ framework, 3 this article investigates how current policies allow for a ‘double charging’ of the taxpayer: public funds finance the initial innovation and stabilise the market through procurement, yet the state fails to ensure equitable prices. This ‘evidence vacuum’ regarding functional outcomes further allow intermediaries to capture public value, reinforcing price rigidity and hindering the universalisation of access.
Against this backdrop, this article addresses the following research question: What structural and institutional factors explain the high costs of assistive products, and how do service delivery models influence accessibility, specifically within the Portuguese context between 2011 and 2022?
The article is structured into four sections. Following this introduction, the methodology outlines the comparative framework and the longitudinal analysis of Portuguese administrative data (2011–2022). The results are organised into three layers: a characterisation of the global AP industry; a comparative assessment of SDM-AP in Portugal, Spain, Italy, and Ireland; and an empirical examination of the Portuguese allocation system, including expenditure trends and technological disparities. Finally, the findings are interpreted through a political-economic lens to identify structural drivers of cost and propose reform pathways aimed at democratising access to assistive products.
Methodology
This research employs a qualitative and integrative comparative policy approach to examine the structural factors shaping AP costs and accessibility. The methodological design is organised into three complementary components:
To capture contextual variation, the article employs a comparative framework that contrasts different national approaches, positioning Portugal as the central case study. 4 The selection of Spain, Italy, Ireland, and Portugal is grounded in their shared trajectory of late welfare state development and the historically significant role of the Catholic Church and third-sector organisations in shaping disability policy. 5 This institutional background enables a substantive comparison of divergent policy pathways and identifies opportunities for innovation. The analytical categories for the comparative mapping (legislative framework, eligibility, funding, etc.) were established based on the WHO 5P model (People, Policy, Products, Provision, Personnel) and the framework used in the Deloitte 6 study on AP service delivery, ensuring consistency with international assessment standards.
The comparative mapping follows the WHO 5P model (People, Policy, Products, Provision, Personnel), as proposed by the WHO, 7 to ensure a multidimensional analysis of the service delivery ecosystem.
The second component consists of analysing administrative data from the Portuguese Assistive Products Allocation System (SAPA) over an 11-year period. This longitudinal analysis identifies trends, ruptures, and imbalances in the implementation of the Portuguese model by observing: — The number of beneficiaries and product volume across four key sectors (Health, Social Security, Employment, and Education). — The evolution of public investment and budget execution rates. — The institutional distribution of provision.
Furthermore, to evaluate the long-term sustainability of the system, expenditure projections for 2035 and 2050 were calculated. These projections utilised the 2022 executed expenditure as a baseline and applied a Compound Annual Growth Rate (CAGR) of 3.43%, derived from the historical budgetary trends observed between 2011 and 2022.
The final component comprises a narrative review of the political economy of assistive technology, innovation, and market models. By synthesising recent contributions on market-shaping, 8 mission-oriented approaches, 9 and the economics of AP, 10 this review contextualises the empirical findings. It identifies knowledge gaps and provides the theoretical foundation for the proposed reform pathways and the democratisation of access.
Results
Characterisation of the assistive products industry
International literature and global datasets indicate that the AP industry has expanded steadily over recent decades. In 2022, the global market was valued at approximately USD 21.95 billion, with projections suggesting growth to around USD 31.22 billion by 2030, corresponding to a compound annual growth rate of 4.5%–5%. 11 Estimates from the Global Report indicate that more than 2.5 billion people require at least one assistive product, a figure expected to exceed 3.5 billion by 2050. 12 Patent data show that innovation between 1998 and 2019 was concentrated in conventional domains such as mobility, built environment, hearing, and vision. 13 Since 2014, emerging technologies, particularly those linked to mobility and enabling technologies, have increased their presence, reflecting convergence with robotics, consumer electronics, and additive manufacturing.12,13 The productive structure of the sector is predominantly composed of micro, small, and medium sized enterprises, except in the hearing aids segment. 14 Across countries, production volumes remain low and personalisation requirements high. National systems reflect these global patterns, with investment frequently concentrated in mobility-related products rather than communication, cognitive, or environmental technologies.
Service delivery models: Comparative analysis
The comparative analysis between Spain, Italy, Ireland, and Portugal reveals significant structural disparities when mapped through the World Health Organization’s 5P model.6,7,15
Policy
At the top of the structural pyramid, legislative frameworks diverge between decentralisation and sectoral fragmentation. Spain and Italy combine national legislation with robust regional regulation.16,17 In contrast, Ireland and Portugal rely primarily on national and sectoral frameworks.18,19 In Portugal, the categorisation of assistive products is rigidly divided into Independent Living (AP-IL), Education (AP-EDU), and Employment (AP-OT), reflecting a governance structure that, while legally centralised, is operationally dispersed across multiple ministries.
Products
The available technological diversity is conditioned by national catalogues. While Spain and Italy utilise standardised catalogues and defined national prosthetic nomenclatures,16,20 Ireland manages access through centralised approved lists. Portugal uses the ISO 9999 standard for its official taxonomy, focusing predominantly on categories ISO 09 (Personal care), 12 (Mobility), 18 (Furnishings and adaptations), and 22 (Communication and information).
Provision
The practical execution of the model reveals the greatest efficiency challenges. Institutional responsibilities are distributed among regional entities in Spain and Italy, and by sector in Ireland. 21 In Portugal, ‘Provision’ is marked by critical fragmentation between the ACSS (Health), ISS (Social Security), IEFP (Employment), and DGE (Education). Implementation mechanisms vary between fixed co-payments and tax deductions in Southern Europe and direct subsidies in Ireland. Portugal is distinguished by a combination of centralised public procurement and reimbursement systems, presenting theoretical total coverage that contrasts with the identified bureaucratic barriers to access.
Personnel
The ecosystem’s engine relies on assessment teams serving as gatekeepers. 22 In the Spanish, Italian, and Irish models, prescription is frequently performed by regional clinical specialists or integrated multidisciplinary teams (HSE). In the Portuguese model, assessment and prescription depend on prescribing physicians within the National Health Service or specialised technicians at Resource Centres (STRC) within the scope of employment and education, creating distinct and occasionally redundant access pathways for the user.
People
Finally, the impact on the user is defined by eligibility criteria. This is the point of greatest divergence: While Spain and Italy establish a disability threshold of ≥33% for universal access, Portugal imposes a more restrictive criterion of ≥60%. Empirical data suggests that this threshold acts as a primary filter for systemic exclusion, effectively preventing citizens with moderate functional limitations from accessing the system, despite its formal universal mandate.
Service delivery models for assistive products (2020).
Evolution of the Portuguese assistive products allocation system (SAPA), 2011–2022
Beneficiaries by sector
Between 2011 and 2022, SAPA supported 171,029 individuals. The Health sector accounted for approximately 94% of beneficiaries, followed by Social Protection (16%), Education (4%), and Employment (2%). Beneficiary numbers were highest in 2011, decreased until 2016, and increased thereafter. The Education sector shows gradual growth from 2014 onwards, while Employment remains comparatively small and variable. 26
Budget execution and funding distribution
People supported by the Portuguese service delivery model of assistive products (N, %) (2011/2022, by department).
Source: SAPA implementation reports (2011–2022) 1 ; compiled by the author.
Execution rate of budget for the acquisition of assistive products in Portuguese SDM-AP (2011/2022), by department.
Source: SAPA implementation reports (2011–2022) 1 ; compiled by the author.
Budget execution patterns varied significantly across departments. The Social Protection sector maintained stable execution rates between 94% and 100%, with its budget expanding to €25.1 million in 2022 to support 3391 beneficiaries. The Health sector remained the primary entry point, accounting for approximately 94% of the cumulative total of beneficiaries (160,634 individuals). However, the number of people served in this sector dropped from 21,573 in 2011 to 14,315 in 2022, while its expenditure rose from €6.2 million to €9.1 million.
The Employment sector displayed the most pronounced fluctuations. In 2011, it executed only 0.51% (€12,627) of a €2.4 million budget, supporting 6 individuals. By 2022, execution reached 72.26% (€2.8 million) for 360 beneficiaries. The Education & Science sector, included since 2014, supported 1057 people in 2022 with an expenditure of €576,964, consistently maintaining execution rates near or above 100%.
For the full 2011–2022 period, the total budgeted amount was €195.86 million, while the total executed expenditure reached €203.42 million. This represents a cumulative execution rate of 103.86% for the entire Service Delivery Model.
Aggregated distribution of funding by ISO class and department (2011–2022) (€).
Source: SAPA implementation reports (2011–2022) 1 ; compiled by the author.
Note. Assistive products (AP) are classified according to the ISO 9999 international standard. The categories analysed include: ISO 04 (assistive products for personal medical treatment); ISO 05 (assistive products for training in skills); ISO 06 (orthoses and prostheses); ISO 09 (assistive products for self-care and personal protection); ISO 12 (assistive products for personal mobility); ISO 15 (assistive products for domestic activities); ISO 18 (assistive products for furnishings and adaptations to build environments); ISO 22 (assistive products for communication and information); ISO 24 (assistive products for controlling, carrying, moving and handling objects and devices); and ISO 30 (assistive products for recreation).
Long-term projections
Drawing on executed expenditure data from 2022 and applying a compound annual growth rate (CAGR) of 3.43% – consistent with historical trends – long-term projections, as presented in Graph 1, indicate increases across all sectors by 2035 and 2050.
26
Expenditure in the Health sector could reach €14.1 million by 2035 and €23.4 million by 2050. Social Protection could approach €65 million by 2050. Allocations in Employment and Education & Science are projected to more than double relative to current levels. Long-term projections of public investment in assistive products in Portugal by sector (2022, 2035, and 2050). Source: Developed by the author using data from SAPA implementation reports (2011–2022).
1
Affordability of assistive products and asymmetries of power
While the literature identifies a multifactorial basis for AP pricing – ranging from production scales to regulatory requirements – the Portuguese data reveals a steady upward trajectory in costs that exceeds these technical justifications. As shown in the longitudinal analysis, the average cost per beneficiary rose significantly, suggesting that price rigidity is increasingly decoupled from actual R&D intensity.
Synthesis of observed patterns
The empirical evidence presented reveals a structurally asymmetric and functionally imbalanced service delivery system. Three interrelated patterns emerge with particular clarity.
First, there is a pronounced sectoral concentration. Although the Portuguese SDM-AP formally operates through a cross-sectoral framework, implementation remains heavily dependent on the Health and Social Protection sectors. Health concentrates the majority of beneficiaries, while Social Protection absorbs most financial resources. Employment and Education & Science, by contrast, display marginal or unstable participation. This configuration reflects differentiated administrative capacities and policy maturity, but also signals limited intersectoral integration in the operationalisation of assistive products.
Second, the system exhibits technological concentration. Public investment is overwhelmingly directed towards mobility-related products (ISO 12), with comparatively low allocation to communication, cognitive, ergonomic, and environmental technologies. This pattern suggests a predominantly compensatory and rehabilitation-oriented logic, rather than a multidimensional approach to autonomy, participation, and citizenship.12,27,28 The narrowing of the technological spectrum is further reinforced by the declining average number of products allocated per beneficiary.
Thirdly, a financial paradox becomes evident. Between 2011 and 2022, the average cost per beneficiary increased substantially, while beneficiary numbers fluctuated and the volume of products per user decreased. Simultaneously, execution rates varied considerably across departments, particularly within Employment. These dynamics raise significant questions regarding efficiency, distributive fairness, and long-term sustainability, particularly in the absence of systematic outcome measurement capable of linking expenditure to tangible gains in autonomy or inclusion.
The absence of impact metrics is not merely an administrative lacuna but an ethical failure in the system’s governance. Without the systematic measurement of autonomy gains through validated instruments (such as QUEST or IPPA), the Portuguese system prioritises the mere provision of the device over the actual functionality achieved. This ‘evidence vacuum’ protects the financial status quo, preventing the demonstration that alternative models – such as open-source software or circular economy principles – could offer identical or superior outcomes at a fraction of the current cost.10,29
Taken together, these patterns suggest that the high costs of assistive products in Portugal cannot be attributed solely to technical factors such as R&D intensity or material specifications. Instead, they reflect structural features of governance, sectoral segmentation, procurement practices, and market configuration. The Portuguese SDM-AP demonstrates formal universality but operational decentralisation across multiple statutory bodies – a configuration that presents challenges to equitable access, influences the range of available technological solutions, and impacts overall systemic integration.
This synthesis provides the analytical foundation for the subsequent discussion, which examines the political and institutional dynamics underpinning these structural imbalances and explores pathways for systemic reform.
Discussion
A political portrait of the assistive products system
The results of this study reveal a set of structural, institutional, and market dynamics that help explain the persistent challenges in ensuring equitable, affordable, and effective access to Assistive Products (AP) in Portugal. When interpreted through a political-economic lens, four cross-cutting themes emerge: affordability constraints, limited technological diversity, governance fragmentation, and entrenched power asymmetries.
Affordability: The financial paradox and ‘double charging'
The sharp rise in the average cost per beneficiary – increasing from €406.25 in 2011 to €1973.77 in 2022 – points to a structural misalignment between fiscal expenditure and service accessibility. This trend is underscored by a 22% decline in the total number of individuals supported (from 24,511 to 19,123), despite a nearly fourfold increase in total executed expenditure (from €9.9M to €37.7M) during the same period. This inverse correlation – where increased public investment yields diminished coverage – mathematically validates the ‘financial paradox’ identified in this study. The 60% disability threshold serves as the operational engine of this paradox, functioning as a mechanism of stratified universalism. 30 By imposing such a restrictive administrative barrier, the system effectively rations access, excluding a significant portion of the population with moderate functional limitations who could benefit from lower-cost, high-impact technologies. To rectify this, the SAPA should adopt a strategy of targeting within universalism, 31 ensuring that resources are prioritised for high-impact interventions without compromising the system’s broad inclusive mandate.
By applying the ‘entrepreneurial state’ framework, 3 it becomes evident that current policies allow for a ‘double charging’ of taxpayers: public funds de-risk the initial innovation through grants and procurement stability, yet the market fails to ensure equitable returns in the form of affordable prices. Even in contexts like Portugal, primarily a technology follower, this persists through the capture of public value by intermediaries and local providers who benefit from public de-risking without translating these benefits into affordable end-user prices. The state is effectively subsidising price rigidity rather than expanding social inclusion.
Technological diversity: A narrow and uneven innovation landscape
The concentration of public investment in mobility-related products (ISO 12) reflects a global tendency to prioritise conventional technologies with predictable demand. In Portugal, over 74% of total expenditure is allocated to ISO 12, while communication and cognitive technologies remain underfunded. This narrow spectrum limits the system’s capacity to respond to diverse functional needs and contributes to unmet demand in domains identified as critical by the WHO. 12 The limited uptake of emerging models, such as mass customisation and open-source hardware, further constrains innovation and user autonomy.
Fragmentation and the ‘evidence vacuum’
Portugal combines formal universalism with operational fragmentation. While the Health sector accounts for 94% of beneficiaries, its reach has contracted by 33% since 2011. Despite serving 7000 fewer people, its expenditure rose by €3 million, suggesting potential for improved strategic procurement and price negotiation mechanisms to address the rising expenditure per beneficiary. Furthermore, the Employment sector shows recurrent under-execution (72% in 2022) and disproportionate budgetary ratios, suggesting that administrative requirements may act as primary barriers to access, rather than purely fiscal constraints. The absence of systematic outcome measurement 29 creates an ‘evidence vacuum’ that prevents the assessment of whether rising expenditure translates into improved autonomy or reduced caregiver burden.
Power asymmetries and institutional gatekeeping
The AP sector exhibits forms of institutional opacity similar to the pharmaceutical industry. Exclusive prescription channels and opaque procurement processes create information asymmetries that reinforce supplier dominance.6,22 These mechanisms do not arise from technical limitations but from political and organisational choices that treat AP as niche commodities rather than essential public infrastructures.
Pathways for structural reform
The empirical patterns identified in the previous section reveal that the high cost of AP in Portugal cannot be explained solely by conventional narratives centred on R&D intensity, specialised materials, regulatory requirements, or market fragmentation. While these factors are real, they are neither immutable nor sufficient to justify the persistent rise in expenditure, the concentration of investment in conventional technologies, or the limited diversification of the AP ecosystem. This section critically reassesses these cost narratives and proposes alternative pathways grounded in innovation, cross-sectoral collaboration, and structural reform.
Rethinking R&D costs: Social conditionalities
Evolution of R&D investment in leading assistive products producers (% of GDP).
Source: Developed by the author using data from the OECD annual GDP and consumption per capita (USD, current prices, current PPPs) dataset and the OECD main science and technology indicators (MSTI) database.
Between 2011 and 2022, these countries maintained robust R&D trajectories. Korea stands out with GERD levels reaching 4.85% in 2022, while its GBARD rose to 1.21%, signalling a strong public commitment to innovation. Germany and Japan maintained GERD levels above 3%, with Germany’s GBARD surpassing 1.0% in 2022. Even in the United States, where private investment is dominant, public expenditure (GBARD) remains a critical baseline for basic research. China’s trajectory further confirms this, with GERD rising to 2.49% alongside rapid economic expansion.
These data demonstrate that the early-stage development costs of assistive technologies are heavily subsidised by the public purse. Consequently, when the State finances basic and clinical research, it must demand social conditionalities – including price transparency and accessibility clauses – to combat the ‘double charging’ of the taxpayer. 3 In the Portuguese context, the current specific cost of ∼€7400 per person in the Social Protection sector reinforces the urgency of reclaiming public value. The high prices paid by the Portuguese system do not merely recover R&D costs; they often represent a capture of public value by local monopolies and intermediaries who benefit from de-risked global innovations without translating these public investments into affordable end-user prices.
Taken together, these data reinforce a central argument: the exclusion of assistive products from major innovation ecosystems is not a technical inevitability but a political choice. Given the limited production scale and low direct economic return of AP, the sector requires an alternative policy framework capable of overcoming the structural constraints inherent to niche industries.
To counter the political and institutional marginalisation of AP within national R&D systems, we propose a structural realignment through the cross-sectoral integration of R&D programmes and the implementation of technological solidarity mechanisms. Public R&D initiatives should incorporate mandatory requirements for technological application in socially relevant sectors, drawing on environmental innovation frameworks where funding is contingent upon minimum quotas for adapting mainstream technologies – such as robotics and additive manufacturing – to AP contexts. 34 This approach is complemented by technological solidarity mechanisms, inspired by EU cohesion policy redistributive principles, 35 which promote the guided circulation of knowledge and resources between high-capacity sectors like aerospace or digital health and the AP domain. Operationalising this shift requires a suite of tools, including interministerial innovation funds for inclusion, the insertion of social clauses in public R&D tenders, and the creation of cross-sectoral platforms and technological convergence laboratories for validation.
Together, these strategies would reposition assistive products as a legitimate and strategic domain of public innovation, aligning national science and technology systems with broader values of inclusion, sustainability, and citizenship.
Materials: Cost, innovation, and opportunities for collaborative procurement
Material quality is a key determinant of AP cost and performance. Premium-range products rely on lightweight alloys, hypoallergenic polymers, and advanced textiles that enhance comfort, durability, and safety.36,37 Budget-range products, by contrast, prioritise affordability, often at the expense of usability and long-term durability. 38
However, the use of advanced materials is not unique to AP. Sectors such as aerospace, automotive, construction, and technical apparel have long adopted lightweight composites, resilient polymers, and eco-efficient materials.39,40 These industries increasingly rely on collaborative procurement, industrial symbiosis, and digital marketplaces for secondary materials,41,42 demonstrating that material innovation can be both sustainable and cost-efficient.
For the AP sector, these dynamics open several opportunities grounded in industrial symbiosis and collective efficiency. While traditional centralised purchasing can increase the risk of standardisation and compromise users’ rights to choice and representation – making it unsuitable for non-hospital assistive products 43 – we argue that a more appropriate alternative lies in collaborative procurement of raw materials and cross-sector partnerships. This approach, combined with resource sharing and reuse through shared logistics and surplus redistribution, can significantly improve predictability and reduce operational costs. Furthermore, participation in high-volume procurement platforms allows for indirect economies of scale that dilute fixed costs without the need for formal consortia. Ultimately, these collaborative practices and efficient material management can substantially reduce unit costs, provided that certification and innovation models remain strictly aligned with the principles of social inclusion and the circular economy.
Mass customisation and distributed manufacturing
To decouple autonomy from market-driven price rigidity, the transition to Mass Customisation and distributed manufacturing is essential. Models grounded in Open-Source Hardware and 3D printing offer a resilient infrastructure to circumvent dependence on global supply chains.44,45 Mass customisation combines modularity, user co-design, and flexible production ecosystems.46,47 By utilising configurators, users act as co-authors of their solutions, reinforcing ownership and emotional resonance – key dimensions of person-centered design.48,49 In small-scale markets like Portugal, this reduces the customisation costs frequently used to justify inflated prices.
These practices align with Articles 4 and 20 of the UN Convention on the Rights of Persons with Disabilities, which call for accessible, adaptable, and user-centred technologies.
Regulatory reform and public absorption of certification costs
Regulatory compliance ensures safety and reliability but imposes significant financial burdens on producers, especially MSMEs.50,51 Certification costs, laboratory testing, and technical audits contribute to high market prices and slow innovation cycles.
To address this, the State should assume a more active role as a facilitator by absorbing part of the regulatory burden through mechanisms similar to those used for orphan drugs.52,53 This transition requires a strategic framework that includes the creation of public funding lines for inclusive certification, the provision of subsidised laboratory testing, and the establishment of formal partnerships between regulatory agencies and research centres. Furthermore, integrating social impact criteria into regulatory assessments is essential to ensure that the evaluation of assistive products transcends technical compliance, prioritising their role as fundamental infrastructures for autonomy and citizenship.
Progressive certification models – already tested in Canada and Norway for digital health and lightweight devices – could accelerate market entry while maintaining safety standards. 54
Opening the market: Competition, transparency, and anti-monopoly measures
Market concentration and opaque procurement processes restrict competition in the AP sector, perpetuating high prices and limiting innovation. Exclusive supply chains, preferential access to prescription channels, and bureaucratic procurement systems hinder the entry of new players and reinforce monopolistic structures.
To counter these dynamics, the proposed measures focus on structural shifts toward open innovation, rigorous oversight, and user empowerment. This transition should be driven by the adoption of open innovation and diversification strategies – such as technological challenges and cross-industry collaboration with sectors like cycling and technical apparel – to stimulate the development of novel solutions. Concurrently, the implementation of anti-competitive oversight, including regular audits and transparency clauses in public procurement, is essential to prevent cartelisation and market distortion. These efforts can be further enabled by digital intermediation platforms that connect users, manufacturers, and clinicians to facilitate agile prototyping and collaborative development. Finally, ensuring user rights and informed choice requires that all suppliers comply with mandatory registration in the National Catalogue of Assistive Products (CNAT), thereby guaranteeing the traceability and quality monitoring necessary for a truly inclusive ecosystem. 55
Market liberalisation is not only an economic imperative but also a democratic and ethical one. Transparent and plural competition enhances diversity, affordability, and functional dignity.
Market leverage and institutional opacity
The traditional drivers of AP pricing, previously discussed in this article, fail to provide a comprehensive justification for the current cost landscape. Instead, the ecosystem has shifted towards a ‘value-based pricing’ logic, mirroring the pharmaceutical industry’s strategy of setting prices according to the maximum fiscal capacity of public systems rather than actual production expenditure.1,2 This decoupling of price from cost suggests that the ‘financial paradox’ observed is not a byproduct of innovation, but a deliberate feature of an opaque market where established suppliers capture economic rents. By treating assistive products as niche commodities rather than public infrastructures, current SDM-AP effectively subsidise private profit-maximisation at the expense of universal coverage.
Addressing these dynamics requires more than technical optimisation; it demands a structural repositioning of the sector grounded in transparency, accountability, and user empowerment. This transformation must be underpinned by the mandatory disclosure of development and production costs through public audits, alongside the creation of public platforms for product comparison to enable informed and competitive choices. Furthermore, a rigorous revision of prescription and funding criteria is essential to prevent systematic favouritism toward dominant suppliers, complemented by the active promotion of reuse, adaptation, and distributed innovation models. Finally, the regulation of lobbying and the implementation of mechanisms to monitor conflicts of interest are crucial to mitigating political influence and ensuring that the ecosystem operates in the interest of the end-user.
While some of these measures have been discussed earlier, they acquire a new dimension here: not as technical reforms, but as instruments to rebalance power between suppliers and users. Democratising the assistive products sector requires confronting the mechanisms of institutional power that sustain inflated prices – recognising that the problem may lie less in the costs themselves than in the political and market structures that protect them.6,12
The concluding section presents the final reflections of this study.
Conclusion
The longitudinal and comparative analysis presented in this article demonstrates that the high cost of assistive products in Portugal is not an immutable technological necessity, but rather a consequence of structural and institutional imbalances.
The findings indicate that the Portuguese SDM-AP has shifted towards a pricing logic that parallels dynamics observed in high-value medical markets, where prices align with the fiscal capacity of public systems rather than production expenditure. This trajectory is reinforced by a lack of comprehensive data regarding functional outcomes – by prioritising bureaucratic provision over the measurement of autonomy and participation, the system undermines its own ability to justify increasing costs.
Moreover, the 60% disability threshold functions as a mechanism of stratified universalism, 30 acting as a systemic barrier that excludes a significant portion of the population with moderate functional limitations. Transitioning from this model towards proportionate universalism 56 through a strategy of targeting within universalism 31 is not merely a social imperative but a necessary structural adjustment. Such an approach would enable the system to prioritise life-sustaining autonomy over generic assistance, ensuring that public resources are allocated where their functional impact on citizenship is maximised.
Finally, by applying the ‘entrepreneurial state’ lens, this study concludes that current policies allow for the ‘double charging’ of taxpayers, who fund initial innovation risks and subsequently pay prices driven by market concentration. Even in a technology-follower context like Portugal, public value is captured by intermediaries who benefit from price rigidity without expanding universal coverage.
Footnotes
Acknowledgments
The author would like to express sincere gratitude to Professor Dr Pedro Encarnação for the initial conversation that inspired the development of this article. The text was subsequently reviewed using version 1.25073.146.0 of Microsoft Copilot.
Ethical considerations
This article does not involve human participants, and therefore informed consent is not required.
Author contributions
Conceptualization, investigation, methodology, writing – original draft, and writing – review and editing.
Funding
The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The results presented in 
: Service delivery models for assistive products (2020), in the section ‘Service delivery models: Comparative analysis’, are based on the author’s doctoral thesis and were funded by the Foundation for Science and Technology, I.P. (Portugal).
Declaration of conflicting interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.