音声ブラウザご使用の方向け: SKIP NAVI GOTO NAVI

ISPO An Asian Prosthetics and Orthotics Workshop '98 in Japan Final Report

| Contents | | Photos | | Previous Page | | Next Page |


Papers

ISPO CONSENSUS CONFERENCE ON APPROPRIATE PROSTHETIC TECHNOLOGY FOR DEVELOPING COUNTRIES

Norman A Jacobs

Introduction

The Consensus Conference on Appropriate Prosthetic Technology for Developing Countries was held in Phnom Penh, Cambodia 5-10 June 1995. It was organised by ISPO in collaboration with the World Health Organisation (WHO) and the United States Agency for International Development (USAID).

ISPO together with WHO and USAID agreed that international and national governmental and non-governmental agencies intending to set up prosthetics programmes in developing countries need guidance as to the most suitable technologies and methods of delivery of services. They require advice on adequate procedures for the evaluation of such factors as effectiveness, cost, quality of fitting and durability. In short the agencies need help in deciding what type of approach is best in different situations. The conference was set up to meet this need.

A total of 94 experts in prosthetics in developing countries were invited to participate in the conference. They included 63 individuals representing 37 agencies and units with prosthetic programmes in developing countries, 16 resource persons and 15 professionals working in prosthetic units in Cambodia.

Agencies and units providing prosthetic services presented papers describing their service provision in terms of:

  • numbers of amputees and levels of amputation fitted;
  • staffing levels including grades and training;
  • prosthetic technology used;
  • evaluation of service;
  • arrangements for transfer to local providers of service.

Other presentations were made covering such topics as:

  • component availability and manufacture in developing countries;
  • components and systems manufactured in the industrial world specifically for use in developing countries;
  • application of CAD CAM in developing countries;
  • assessment and evaluation of programmes;
  • education and training;
  • technology transfer;
  • quality control.

Literature reviews were made that covered:

  • rehabilitation of the amputee in the developing world;
  • prosthetics in the developing world.

There were plenary discussions on all these presentations and there were small group syndicates on various topics related to the subject. This provided a framework for further discussion that led to the formulation of guidance on appropriate technologies and on the related areas of assessment, organisation and co-ordination of projects.

The purpose of my presentation today is to present the conclusions and recommendations arising from the consensus conference.

Establishment and organisation of projects

1
The factors to be considered in setting up a prosthetic project in a developing country were discussed and agreed. These include:
  • need to go into the country and the motivation to do so;
  • needs assessments and surveys within the country with regard to:
    1. number of amputees;
    2. existing services and national counterparts;
    3. existing production facilities;
  • participation of local government officials, ministries, private groups, etc.;
  • co-ordination of governmental and NGO activities;
  • resources available/ the financial responsibility whether it be governmental, donor or agency/and the capacity of the local organisations to take over the costs;
  • whether the proposed project is sustainable or not;
  • marketing and advocacy of the project in order to determine whether there is a public awareness and interest;
  • determine the external context with regard the laws and legal system of the country;
  • planning should take account of such factors as:
    1. access to facilities;
    2. transportation;
    3. security problems;
    4. location of recipients of the service;
    5. involvement of the disabled in the planning processes;
  • awareness of the national plan or structure of local services;
  • implications of any educational or training requirements required as well as awareness of the existing education and training possibilities in the country or region.
2
The principal criterion in considering setting up a project is that it has been proposed or supported by the national government. Very few, if any, projects will succeed in the long term unless they have the backing of government.
3
Every programme must be built up on the demonstrated ability of providing a system of service, training and sustainability. They must show that they can offer a good service for disabled people, have training possibilities for the local counterparts and are designed to last after the donor agencies have left.
4
There should be a relationship between the government, donors, NGOs, technical and professional organisations (eg ISPO) and the consumers (or users) of the service.
5
There should be a relationship between agencies providing prosthetic services and other agencies providing surgical/medical or education/training services within the existing framework(s) of the national programme.
6
Consideration should be given to combining prosthetics and orthotics programmes. Although the conference was only looking at prosthetic technology it recognised the need to combine prosthetics and orthotics.

Assessment of need

7
The factors to be considered in assessing need when proposing a project were specified and agreed. These include:
  • What are the existing prosthetic/orthotic services, associated clinical services and social services in the host country?
  • Are there any outside services (NGOs) in the country? Are they in need of help?
  • Is the host government interested in outside participation and have they requested help?
  • What is the magnitude of the problem with regard to numbers, severity and location?
  • What is the level of socio-economic development in the host country?
  • security and logistics;
  • What is the estimated cost of the project to the donor agency and to the country itself?
  • What are the priorities and the commitment of the host government and its allocation of resources?
  • Are there local road and transport systems?
  • What is the level of the local technology?
  • Are there particular needs due to the culture and environment?

Interagency co-operation

8
In order to optimise the use of resources co-operation between agencies working in the same country or region is strongly encouraged. Repetition of efforts should be avoided if at all possible as any repetition eats up valuable resources.

Co-operation might include collaboration in bulk purchase, sharing facilities and the development of a common database for sharing information.

Tasks may be split as, for example, some agencies may be better equipped than others to produce components whilst others may be more suited for education and training purposes.

Sustainability

9
All prosthetics projects should contribute to the development of a long-term sustainable national service to provide prosthetics services for all social groups.

The requirements and the steps that should be taken to ensure this were identified. These include:

  • initiation of discussions with the host government;
  • commitment of host government;
  • advocacy and empowerment of beneficiaries eg bring conferences and other events and activities to the areas where the problems are;
  • development of a national plan on the part of government that should address management as well as technical and financial aspects;
  • The plan must have provision for updating and evaluation;
  • training of local personnel to take over and run the project before foreign agencies leave;
  • Donor or implementing organisation should facilitate or initiate discussions and brainstorming sessions on the development of options for sustainability with the host government;
  • provision of equipment;
  • institute methods of human resource development in order that local people working in the project have the opportunity to develop professionally;
  • minimise the brain drain of educated and trained local personnel;
  • All projects, activities and programmes should be flexible and adaptable. They should contain a procedure that formalises feedback, identifies weaknesses, provides evaluation and provides for adjustment.

Cost information

10
The problems associated with interpreting cost information were discussed and it was found that there were many different methods of assessing costs of projects and the cost of individual prostheses.

It was agreed that cost presentation should be standardised by individually identifying capital costs, administration costs, materials, labour etc.

11
Some proportion of the cost of the prosthesis should be paid, where possible, by the recipient to give him/her an appreciation of its value. Services should however, be available to all regardless of the ability to pay.

Evaluation

12
The criteria to be considered when evaluating an ongoing or completed project were specified and agreed. These include:
  • infrastructure of the project;
  • staffing of the project including both local and expatriate personnel;
  • Is there an integrated team approach?;
  • What are the possibilities for local staff development?;
  • Where is the funding coming from and how it is being used?;
  • population covered by the project including estimates of the numbers and types of disability;
  • range of devices supplied;
  • materials used;
  • quality of materials used;
  • Are there locally produced components available and are they being used?
  • application of prosthetic principles for fit and alignment. Do the prostheses fit well?
  • Does the prosthesis function well?
  • quality of services provided;
  • quantity of prostheses provided;
  • disabled person's attitude and knowledge of the project and treatment;
  • What is the delivery system?
  • Is the workplace safe for the personnel?
  • integration of the project as part of the national service;
  • What is the sustainability of project?
  • What is the short term and long term viability of project?

It was further agreed that there was a need to develop methods to provide performance indicators and outcome measures to evaluate projects.

Community-based rehabilitation (CBR)

13
It was agreed that there is a range of simple to more complex community-based rehabilitation (CBR) models, i.e. from totally voluntary village workers to a more structured attachment to the Health and Social Care system.

The role of CBR in a structured prosthetic service was outlined as follows:

  • outreach activities resulting in increased accessibility to services;
  • patient referral for prosthetics services and monitoring after fitting;
  • patient education;
  • basic maintenance of prostheses and monitoring when repairs and replacement might be required;
  • provision of a communication channel to the national prosthetics delivery system;
  • local access and accessibility for disabled people;
  • social access for disabled people;
  • to stimulate the local population to accept and help the disabled;
  • feedback and information gathering.

The inclusion of CBR provides a splendid opportunity to involve disabled persons in the provision of services.

Involvement of disabled persons

14
Disabled persons should be consulted in the planning of activities. All too often only the professionals involved do the planning of services. There is much to be learned and gained by involving informed disabled people in the planning processes.

Acute or conflict situations

Many prosthetics projects in developing countries are established to provide prostheses to amputees who have lost their limbs as a result of an acute or conflict situation.

15
Prosthetic services in conflict situations are a critical need and should be provided whenever the safety and security of the disabled persons and the prosthetics personnel can be reasonably assured.
16
Projects in conflict situations should be designed to provide maximum availability of, and access to, appropriate devices and services and be amenable to long term follow-up services.
17
Initial response should be limited to temporary camps of dislocated people or refugees in somewhat secure and safe areas.

Simple technologies may be used for immediate fitting. However, even in these conditions, sustainability should have priority.

Relief programmes should be designed to provide the maximum input for the maximum number of people in a short period of time.

The time available in which to work may often present itself as a "window of opportunity" and the agencies supplying the relief programme must be in a position to take advantage of it.

18
In the absence of a professional infrastructure, the use of prosthetic kits for mass distribution in these situations was not recommended.

Appropriate technology

19
Much time was spent at the conference in trying to define appropriate technology and the following definition was agreed.

Appropriate technology is a system providing proper fit and alignment based on sound biomechanical principles, which suits the needs of the individual and can be sustained by the country at the most economical and affordable price.

Unless this definition can be met, regardless of the materials or components used, the end result will be totally inappropriate.

20
A dialogue should be established between donors and governments to reach a consensus on the technology (or technologies) to be adopted in a particular country or region. There was no one particular technology that was seen to be a solution to all.

Materials

21
A number of factors should be considered when choosing materials for prostheses. These factors include:
  • cost;
  • local availability of the materials, that is whether they are readily available in the country. Such materials do not have to be indigenous to the country;
  • whether the material can be adjusted easily without using expensive or difficult processes;
  • durability;
  • cultural requirements. For example the use of leather from some animals might be forbidden in some cultures;
  • The material should be biocompatible;
  • Working with the material should not be a threat to the safety of the person working with it;
  • The supply of the material must be sustainable;
  • The material must be able to cope with the climate or the terrain in which it will be used;
  • ease of repair;
  • the equipment available.
22
The advantages and disadvantages of the use of different materials in different environments were tabulated. This information is displayed in Table 1.
23
ISPO should produce recommendations on the use of polypropylene. The International Committee for the Red Cross (ICRC) have produced a prosthetic system using polypropylene which incorporates the possibility of using locally produced polypropylene components and results in the production of a relatively cheap prosthesis. It is necessary to undertake an independent evaluation of this system to determine its place in appropriate technology. I shall touch upon this later.
24
It was considered that there should be unanimous acceptance by all the groups involved of the materials to be used in an individual country. This would lead to similar education and training requirements for personnel permitting their movement within the country.

Table 1: Advantages and disadvantages of different materials in different environments.

Material Advantages Disadvantages
Wood Biocompatible
Generally available
Simple tools
Easy to repair locally
Deteriorates in wet climates
Leather Moulds easily
Generally available
Biocompatible
Easy to repair locally
Deteriorates quickly
Deforms
Requires reinforcement
Hygiene problems
Mild steel Easy to weld
Strong
Generally available
Easy to repair locally
Corrodes
Fatigues
Heavy
Aluminium Light
Generally available
Fatigues
Laminating resins Current accepted technology
Cosmetic
Water resistant
Strong
Worker safety (carcinogenic)
Difficult to repair locally
Short shelf life
Requires imported materials
Fatigues
Requires equipment
Thermoplastics Lightweight
Water resistant
Strong
Recyclable
Long shelf life
Imported
Requires equipment
Difficult to repair locally

Components

25
Prosthetic feet, joints and suspension systems are the major contributors to a reduced prosthetic life span.

The foot is the component of the prosthesis that fails most frequently. Easy replacement of the foot, possibly by the amputee, should therefore be considered an important design feature of a foot if more durable feet cannot be produced.

26
In order to monitor failures in components, service units should maintain records of patients attending for prosthetic repairs giving details of the component failure and duration of its use.
27
An important part of appropriate technology in respect of affordability and sustainability is related to the local manufacture of components. The majority of developing countries cannot afford to import expensive components from the industrial world. Every effort should be made to encourage the local or regional production of components.
28
Quality control issues are regarded as critical in the production of components. Production of components in the developing world is no different and quality control systems should be used to assure product and programme standards. Ultimately the function of the components provided and their life span measure quality.
29
The need to develop a simple standardised mechanical testing of components was identified.
30
The testing and documentation of products, prior to their introduction, was seen as an obligation of NGOs as part of the process of establishing a project.

Workshop safety

31
Workshop safety in developing countries gives rise for concern. This applies not only to the way in which machinery is used and maintained but also to the types of materials that are used and the ways in which they are processed.

Maximal safety of installations and machinery should be mandatory although it is recognised that the ability to control work practices is limited.

Clinic team

32
Whenever possible a clinic team approach, including the disabled person, should be adopted when providing prosthetic services.
33
The social worker should be included in the clinic team and used to evaluate prosthetic use and the follow-up of disabled persons.

Socket fit

34
Acceptable socket fit should provide the amputee with comfort and function.

Modification of socket fit with respect to cultural and occupational needs must be considered.

CAD CAM

35
Since modern technologies are used in the developing world it is not logical to exclude CAD CAM and thereby discount its current use and future potential.
36
CAD CAM may be a suitable technique in appropriate circumstances but it might divert funding from more effective techniques.

The use of CAD CAM in developing countries was found to be a contentious issue and no firm conclusions about the use of CAD CAM in the developing world was reached at the conference.

Education and training

37
The need to educate and train personnel for developing countries following ISPO guidelines was endorsed. John Hughes, the Chairman of ISPO's Education Committee shall be talking about this subject tomorrow.
38
Specialised training courses should be provided for prosthetists from industrial countries to prepare them for work in the developing world.

Information

39
The ISPO database of information on prosthetics and orthotics is now located in the National Centre for Training and Education in Prosthetics and Orthotics, University of Strathclyde, Glasgow, Scotland.

Summary

Consensus was reached on the following topics:

  • the priorities in prosthetic design;
  • factors to be considered when choosing materials;
  • the need to produce feet of greater durability;
  • barriers to establishing an adequate prosthetic service;
  • True and full costs of projects and individual fittings should be displayed;
  • need for quality control;
  • definition of acceptable socket fit;
  • need for data collection and exchange.
  • co-ordination of efforts in the same country or region.

No consensus was reached on:

  • an acceptable life span for a prosthesis;
  • the appropriateness of CAD CAM in developing countries.

Outcomes

The following outcomes of the conference have been realised:

  • There has been evidence of greater efforts amongst different NGOs and other agencies working in a country or region to collaborate more closely;
  • A meeting was held in Washington, USA in January 1996 under the auspices of USAID to look at the recommendations of the conference. Representatives of organisations receiving funding from USAID to run projects attended it together with some resource persons. The meeting also attempted to determine the factors to be used when evaluating the effectiveness of projects. This is important not only to USAID, because of the amount of money it is putting into different projects throughout the world, but also to all other agencies who are funding or running projects;
  • A conference was held in Wuhan, China in November 1996 by the German Foundation for International Development (DSE) and the German Agency for Technical Co-operation (GTZ). It brought together workers from GTZ projects around the world, representatives of major international and governmental and non-governmental agencies and experts in orthopaedic technology and health care provision. The aim of the meeting was to produce a framework document and in particular a 'declaration' which would guide the development of orthopaedic technology activities in the developing world into the next millennium. The conference built on the outcome of the ISPO Consensus Conference on Appropriate Technology. In particular the conference focused on rehabilitation as part of primary health care including community-based rehabilitation; the financing of health care in developing countries; education and training; methods and procedures in appropriate technology; and objectives and performance indicators of orthopaedic care systems. Copies of the report of this meeting are available from the GTZ headquarters in Germany;
  • A project to evaluate the International Committee of the Red Cross (ICRC) polypropylene prosthetic system is at present underway in Vietnam. It is being run by the GTZ in association with ISPO and with the co-operation of ICRC who are supplying the components free of charge. Altogether 50 trans-tibial and 25 trans-femoral amputees will be fitted who will come from both urban and rural areas. Different aspects of their fitting shall be evaluated including cost, ease of use, technical aspects and medical aspects. It is anticipated that the preliminary results of this evaluation will be available at the ISPO Congress in Amsterdam;
  • ICRC has started to devise a system for cost presentation of their prostheses.

Conclusion

In conclusion I would like to say that the ISPO Consensus Conference on Appropriate Prosthetic Technology was a very successful event. Not only did it examine the subject in depth but also it brought together for the first time representatives of the major international and national governmental and non-governmental agencies working in prosthetics in developing countries. There is a growing feeling of co-operation amongst these agencies and the conclusions of the consensus conference are beginning to be implemented.


Commemorating the Mid-Point of Asia and Pacific Decade of Disabled Persons
ISPO An Asian Prosthetics and Orthotics Workshop '98 in Japan Final Report
- Papers : ISPO Consensus Conference On Appropriate Prosthetics Technology for Developing Countries -

Editors:
Eiji Tazawa
Brendan McHugh