REPORT OF THE
TECHNICAL WORKSHOP

1. Organization of the meeting
2. Opening of the meeting
3. Highlights of presentations and field visit observations
4. Critical issues
5. Recommendations
6. Adoption of the report
7. Closing of the workshop

I. Organization of the Meeting

The Technical Workshop on the Indigenous Production and Distribution of Assistive Devices was convened by the Economic and Social Commission for Asia and the Pacific (ESCAP), at Madras, Tamil Nadu, from 5 to 14 September 1995, and hosted by the Government of India, through its Ministry of Welfare, in collaboration with the Government of the State of Tamil Nadu. The Spastics Society of Tamil Nadu assisted in the arrangements for the Madras segment of the Workshop. WORTH Trust assisted in the field visit arrangements.

Attendance

The Meeting was attended by government officials, technicians and rehabilitation specialists from the following members and associate members of ESCAP: Bangladesh, Bhutan, Cambodia, China, Fiji, India, Indonesia, Malaysia, Maldives, Myanmar, Nepal, Pakistan, Philippines, Sri Lanka, Thailand and Viet Nam.

The United Nations Development Programme (UNDP) attended the Workshop.

The following non-governmental organizations and other organizations were represented: CBR Development and Training Centre (CBRDTC), Handicap International (HI), Pusat Rehabilitasi YAKKUM and University of Malaya (UM).

In addition, there were resource persons and observers from government agencies and other organizations in India.

The following experts assisted the secretariat in conducting and servicing the workshop: Mr. Jouko Kokko, Senior Planning Officer, National Research and Development Centre for Welfare and Health (STAKES), Helsinki, Finland; Mr. C. Antony Samy, Managing Director, WORTH TRUST, Katpadi, Tamil Nadu, India; and Mr. David Werner, Founding Member, HealthWrights, Palo Alto, U.S.A.

II. Opening of the Meeting

His Excellency, the Honorable Minister of Welfare, Government of India, Mr. Sitaram Kesari, presided over the opening session. Her Excellency, the Honorable Chief Minister, State of Tamil Nadu, Madam J. Jayalalitha was the Chief Guest. A keynote address was delivered by Mr. A.P.J. Abdul Kalam, Scientific Advisor to His Excellency, the Prime Minister, Government of India.

Her Excellency, the Honorable Minister of Social Welfare, Government of Tamil Nadu, welcomed the participants and guests to Madras.

On behalf of the Executive Secretary of ESCAP, the Chief, Disadvantaged Groups Unit, Social Development Division, ESCAP, delivered a message of welcome to the participants of the workshop. Warm appreciation was expressed to the Government of India and the Government of the State of Tamil Nadu for their hosting of the workshop, generous hospitality and assistance in the local arrangements.

A. Election of officers

The Meeting elected the following Bureau:

Chairperson: Mr. R. Saha, Director, Department of Science and Technology, Government of India;

Vice-Chairperson: Mr. Zou Jian Qiang, Deputy Director, Pharmaceutical and Health Division, State Science and Technology Commission, China;

Vice-Chairperson: Mr. Jokatama Toga, Executive Director, Fiji National Council for Disabled Persons;

Vice-Chairperson: Ms. Kamolpun Punpuing, Public Welfare Officer, Office for the Committee for Rehabilitation of Disabled Persons, Department of Public Welfare, Ministry of Labour and Social Welfare, Royal Thai Government;

Rapporteur: Ms. Catalina Fermin, Assistant Bureau Director and Officer-in-Charge, Bureau of Disabled Persons' Welfare, Department of Social Welfare and Development, Philippines.

B. Adoption of the agenda

The Workshop adopted the following agenda:

1. Opening of the workshop and exhibition on assistive devices.

2. Election of officers.

3. Adoption of the agenda.

4. Review of experiences in the ESCAP region concerning the indigenous production and distribution of assistive devices.

5. Government and NGO contributions to the development and distribution of assistive devices: Indian experience.

6. Issues concerning standardization, distribution, maintenance, training and implementation.

7. Hi-tech and low-cost: Meeting the challenge through research and development (R and D).

8. Field observation of modalities for the production and distribution of assistive devices for the poor.

9. Formulation and presentation of recommendations for follow-up action by participants, including on technical cooperation among developing countries (TCDC).

10. Closing of the Workshop.

III. Highlights of Presentations and Field Visit Observations

Below are the highlights of the presentations by participants and resource persons, and the main observations of the field study programme (see annex I for the field visit notes).

A. Presentations

1. National capacity for the production of assistive devices was limited in many countries due to a lack of financial resources and/or technical skills.

2. With the exception of a few countries in the ESCAP region, most countries imported assistive devices from developed countries, including those outside the region (Denmark, Germany, Japan, Netherlands, Norway, United Kingdom and the United States of America). Devices from China, India and Singapore were also imported. Devices for people with visual impairments and hearing impairments were predominant among the items imported. Most ESCAP developing countries also imported devices for persons with locomotor impairments.

3. In the case of some ESCAP developing countries, the limited progress concerning assistive devices was mainly due to the non-availability of raw materials and components in the local market.

4. Furthermore, there were too few persons with the necessary technical skills to make a significant difference in indigenous innovation and production.

5. Several countries in the ESCAP region did not have the infrastructure, including schools and production workshops, for training technicians.

6. There was general concern over the difficulties in finding spare parts for the repair and maintenance of commercially-available assistive devices, especially the imported ones.

7. Suppliers of assistive devices were often unaware of the social, cultural, economic and environmental circumstances of people with disabilities, particularly those in slums and rural areas. Many of the models of assistive devices available in ESCAP developing countries were based on designs developed in western societies, primarily for hospital use rather than for community living.

8. Although many countries had adopted a policy of reduction of or exemption from customs duty, in practice the red tape involved posed major obstacles.

9. As most countries in the ESCAP region did not have formal standards with respect to assistive devices, standards could be developed in order to enhance the quality of the devices and facilitate intra-regional exchange of technologies. In that regard, informal standards, focusing on safety and usability, could be developed.

10. Many of the important breakthroughs in assistive devices had been achieved by disabled persons themselves in the course of their attempts to improve upon unsatisfactory designs.

11. There was interest in enhancing intra-regional cooperation on the training of trainers in the skills required for the production of low-cost, and culturally and environmentally appropriate assistive de- vices.

B. Field visit observations

Role models

1. Disabled persons who worked in rehabilitation served as excellent role models for other disabled persons requiring assistive devices. Amputees and paraplegic persons not only provided their peers with moral support, they were also rehabilitation instructors and sources of new ideas for innovation in assistive devices.

Choice

2. In most spinal cord injury programmes, it was standard rehabilitation practice to issue wheelchairs to paraplegic persons, especially those with lower back injuries (T-10 or below). However, given the unsuitability of wheelchairs to the rural terrain and limited livelihood options for poor persons with disabilities in the rural areas, ways had been developed to train paraplegic persons in the use of calipers. It was noteworthy that the rehabilitation programme of the Christian Medical College (CMC), Vellore, had developed, in close consultation with disabled persons, a rehabilitation regime which gave spinal cord-injured persons the choice of using calipers so that they could continue in productive manual labour activities in the rural environment.

Importance of long-term follow-up

3. In the institution-based rehabilitation programme of CMC, the trauma of beginning a new life with assistive devices was eased through strong emphasis on building sensitive interpersonal relationships based on trust between the staff and their patients. Systematic and long-term follow-up of former patients following their return to community life generated useful information for improving the devices produced and related services. The adaptation of a local cultural activity (mela) into an annual week-long rehabilitation mela bringing together former patients and their family members provided an important means of mutual support among former patients and between patients and staff. The follow-up involved good record-keeping of the progress (or deterioration) of the former patients. The focus of activities at all stages of that programme was on the persons with disabilities and the provision of comprehensive support, including counselling, for them to adapt to their new lives.

Community action and children with disabilities

4. An association of parents of children with disabilities was a central force in the organization of rehabilitation and other services at the community level (Gandhi Rural Rehabilitation Centre, Alampoondi). Many problems which could not be easily solved by individual families were effectively addressed by the association. Among the significant achievements of the parents' association was the enrollment of their disabled children in regular schools. The level of confidence and self-esteem of the children was impressive, reflecting the harmonization of parental support, use of appropriate assistive devices and the disabled children's smooth inclusion in the community.

5. A transitional school (organized by WORTH Trust) for disabled village children provided them with an opportunity to receive physiotherapy and tuition, as well as to obtain the requisite devices, to enable them to enroll in regular schools upon return to their villages. The transitional school programme included training parents in basic rehabilitation.

Skills and employment to fight stigmatization

6. Engineering equipment was adapted and training courses conducted for persons affected by leprosy so that they could attain a high level of skills and pride in their work. A factory (WORTH Trust Industries) employing this group of persons who were severely stigmatized, worked three shifts and produced high quality components for national and international industries. Girls with disabilities were being trained in electronic and electrical trades, as well as computer programming. Blind persons employed in the factory used lathes and precision instruments with braille markings.

Innovations

7. A wide range of innovations in assistive devices that had been developed in close cooperation with leprosy-affected persons was observed (Schieffelin Leprosy Research and Training Centre, Karigiri). The innovations were the outcome of continuous research and improvisation aimed at protecting people who had lost their ability to sense pain and heat. One example was the microcellular rubber used in the production of protective foot wear; it presented good possibilities for commercialization and income-generation for the Hospital. The experience gained by the Hospital was used to develop audio and visual materials for the prevention of leprosy and improvement of public awareness of leprosy.

8. In many cases, the design of innovations originated from adaptations by disabled persons themselves to meet their daily needs. For example, a young man without one arm, about to be married, was concerned about self-sufficiency in toileting. In his culture, after defecation, water was used for cleansing. Together with a rehabilitation team, he invented a siphon device so that he could apply water and wash himself with one hand.

Rural camps

9. Rural camps organized by a voluntary organization (MUKTI, Madras) and another organized by a district rehabilitation centre (DRC, Chengelput) provided devices within a short period for large numbers of persons who could not easily travel to urban areas for their prostheses and orthoses. The production processes used were simple, fast and based on locally available materials.

10. It was observed that, when large assistive devices such as tricycles were distributed in urban centres to persons living in remote areas, often the beneficiaries had no means of transporting the devices to their homes.

IV. Critical Issues

Based on the presentations, field visit observations and discussions, the participants prepared notes on some critical issues, to serve as background information to the recommendations of the Workshop. The notes on critical issues are contained in annex II of this report.

V. Recommendations

Below are the recommendations of the Technical Workshop on the Indigenous Production and Distribution of Assistive Devices, held at Madras, Tamil Nadu, India, from 5 to 14 September 1995. They include definitions of assistive devices, as well as principles concerning their design, production and distribution. There are general recommendations concerning the subject of the Workshop. In addition, there are also specific recommendations covering prostheses and orthoses, as well as devices for spinal cord-injured persons, persons with multiple disabilities, including persons with cerebral palsy, persons with visual impairments, and hearing-impaired persons.

The recommendations were developed taking into consideration Section 10 on "Assistive Devices" of the Agenda for Action for the Asian and Pacific Decade of Disabled Persons, and related targets for its implementation.

A. Definition of assistive devices

Assistive devices are any devices that directly help persons with disabilities in undertaking activities of daily living (ADL), pursuing an education, acquiring access to information, enjoying freedom of movement in the built environment, working, and engaging in leisure activities. In addition to improving physical performance, assistive devices should also enable persons with disabilities to fulfil their aspirations.

Assistive devices include those which may be used by disabled persons on their own or with the support of other persons. Devices used for rehabilitation, and vocational skills development may also be considered assistive devices.

Assistive devices may be grouped into the following categories:

1. Devices for persons with locomotor disabilities (e.g., wheelchairs, trolleys, tricycles, calipers, braces, crutches, walkers and artificial limbs);

2. Devices for persons with multiple disabilities, including persons with cerebral palsy (e.g., communication boards, adapted crockery and cutlery, and other devices used by persons with locomotor disabilities);

3. Devices for persons with visual impairments (e.g., braillers, low-vision devices, white canes, adapted precision instruments, talking clocks and watches, educational devices and adapted toys);

4. Devices for persons with hearing impairments (e.g., hearing aids and telecommunication devices).

B. Definitions of specific devices

1. Prostheses and orthoses

1. Prosthesis

   A prosthesis is the replacement for a lost part of the body at the extremities. It may either be functional or cosmetic or both.

2. Orthosis

   An orthosis is an appliance to restore function to a paralysed or neurologically affected limb or to prevent its further weakening.

2. Assistive devices for persons with spinal cord injury (SCI)

Assistive devices for persons with spinal cord injury (SCI) are devices which enable persons whose limbs have been affected by the injury to move and to maintain good health, despite the loss of sensation (and the inherent risk of pressure sores), as well as loss of bladder and bowel control.

The following are among the common devices for persons with SCI:

1. Wheelchairs and wheelchair cushions:

   As most persons with spinal cord injury (SCI) are non-ambulatory, wheelchairs are the most important mobility device for them.

   Good wheelchair cushions are an important means of preventing pressure sores, which is a common cause of death among persons with SCI in developing countries.

2. Standing frames:

   Standing frames which enable all persons with SCI to spend some time everyday in an upright position help to maintain their bone strength, as well as prevent osteoporosis, kidney stones (a common post-SCI problem) and other urinal complications.

3. Bladder control devices:

   Devices (and techniques) that enable persons with SCI to control bladder and bowel functions are the key to their active participation in community life.

   An essential bladder control device is a catheter. A catheter is a thin plastic or rubber tube which is inserted into the urine opening and into the bladder to drain urine. A catheter which is changed intermittently, e.g., every four hours or so, is considerably safer (lower risk of infection) than a permanent catheter which is usually changed only fortnightly.

   A clean plastic water container, attached to a wheelchair, tricycle or trolley, can be part of the bladder control equipment to prevent bladder and kidney infection. Such access, especially when the weather is hot, makes it possible for spinal cord-injured persons to drink the large quantity of water needed to avoid infection.

   Wheelchairs and trolleys can be made with holes underneath; removable containers can be placed under the holes to facilitate bladder management.

3. Assistive devices for persons with multiple disabilities, including cerebral palsy

Assistive devices for persons with multiple disabilities, including cerebral palsy (CP), are any devices which facilitate or improve their physical, mental, psychological and social functioning. The devices should make possible the achievement of maximum independence and enable the users to fully develop their abilities.

The main types of assistive devices useful for persons with CP include the following:

(a) Devices for activities of daily living, e.g., adapted crockery and cutlery;

(b) Communication devices, e.g., communication boards, hearing aids, and audio-visual aids;

(c) Mobility devices, e.g., walkers, wheelchairs and tricycles;

(d) Positioning devices, e.g., splints and special chairs;

(e) Educational devices, e.g., learning and teaching aids, stimulation aids, and computers;

(f) Recreational devices, e.g., swings and toys;

(g) Vocational devices, e.g., adapted tools;

(h) Devices for therapy, e.g., standing frames, gaiters, balancing balls.

4. Assistive devices for persons with visual impairments

According to a WHO study undertaken in 1966, there were no less than 65 definitions of legal blindness. One definition, however, on which there is most agreement, is the following:

A blind person is a person so blind as to be unable to perform any task for which eye sight is essential.

On the other hand, many people with visual impairments have some residual vision, which can be effectively utilized by the provision of an appropriate assistive device. A partially sighted person can be described as:

A person with visual handicap who has impairment of visual functions even after treatment or standard refractive correction and has a visual acuity (binocular) of less than 6/18 or a visual field of 10 from the point of fixation, but who uses or is potentially able to use vision for performing a task for which eye sight is essential.

From the definitions of visual impairment, there emerge two categories of visually impaired people having similar, but at the same time different, prognoses and requiring different management regimes.

Assistive devices for users with visual impairments may be further divided into two categories: devices for blind persons and devices for persons with low vision.

1. Assistive devices for blind persons

   Devices for blind persons are composed of orientation and mobility devices, educational devices, as well as devices for daily living, employment, and recreation. They include the following:

   (i) Orientation and mobility devices, e.g., white canes, laser canes and ultrasound canes;

   
   

   (ii) Educational devices, e.g., braille writing frames and stylus, braille books and paper, talking books, arithmetic and algebra frames, geometrical kits, duplication sheets, abacus, as well as raised maps, charts and globes;

   
   

   (iii) Devices for daily living, e.g., liquid level indicators, measuring tapes, talking watches and clocks, braille watches and alarm clocks, signature guides, and needle threads;

   
   

   (iv) Devices that facilitate employment, e.g., speech synthesisers, braille typewriters, braille shorthand machines, computerized braille embossers and printers, and devices which modify any special machines or instruments to enable visually- impaired persons to use those machines and instruments;

   
   

   (v) Recreational devices, e.g., special chess boards, playing cards, as well as audible cricket balls, basket balls and footballs with sound beepers, and peg boards.

2. Assistive devices for persons with low vision

   A low vision assistive device is any device which enables persons with low vision to see better. According to design and function, low vision devices can be broadly placed in three categories: optical, non-optical and electronic.

   (i) Optical devices consist of one or more lenses placed between the eye and the object to be viewed, which increase the size of the image on the retina.

   The most commonly used optical devices are magnifiers, telescopes, contact lenses, and field expanders.

   
   

   (ii) Non-optical devices do not involve lenses or mirrors. They are devices which alter environmental stimuli through the use of illumination, contract and spatial relationships.

   Non-optical devices include large print books (N18 size), lamps, adjustable desks, tints, and typoscopes.

   
   

   (iii) Electronic devices include large print computer monitors, closed circuit television sets, as well as talking watches and calculators.

5. Assistive devices for persons with hearing impairments

Assistive devices for persons with hearing impairments include hearing aids and listening devices which enable users to listen better through a sensory-substitution method, or which act as alerting devices.

C. General principles concerning assistive devices

The following are general principles concerning the design, production and distribution of assistive devices.

(a) Every disabled person has different needs, aspirations, abilities and potential. Assistive devices are more likely to fully meet the needs of individual persons with disabilities when the individual is involved in defining her/his own needs, as well as in designing and testing the devices. Rehabilitation workers and technicians must work with disabled persons as equals and as partners in a problem-solving approach to decisions that empower persons with disabilities.

(b) The choice and design of assistive devices should take into account local customs, culture, the physical environment (built and natural, including climatic conditions), economic conditions and lifestyle of users and their communities.

(c) Wherever possible, persons with disabilities should be given priority for training and work in all areas of rehabilitation, including the production and distribution of assistive devices.

(d) Assistive devices must be adapted to fit the individual user; the user should not be forced to fit the device.

(e) In resource allocations, as well as policy and programme development, support should be directed at strengthening the development of local skills for small-scale, community workshops that can produce custom-made devices to meet individual needs.

(f) Every effort should be made to use locally-available materials and other local resources for production, repair and maintenance, with emphasis on encouraging the involvement of community craftpersons, mechanics and welders.

(g) The science and art of designing and creating assistive devices should be demystified and terminology simplified so that persons with disabilities themselves and members of their communities can make and adapt the devices.

(h) In addition to formal research and development, greater emphasis should be given to innovation at the community level, as well as with disabled persons and their families. Collaboration among socially conscious researchers in applied science and technology, users of assistive devices and craftpersons should be encouraged to enhance progress in indigenous design and production.

(i) Assistive devices should not be viewed as an end in themselves but as part of a process to enable persons with disabilities to achieve their full potential and participate as equals in community life.

(j) In the case of many assistive devices, it is essential to promote training in their use and regular follow-up on their continued appropriateness. For children with disabilities, particularly those with multiple disabilities and/or cerebral palsy, frequent review, involving the use of a series of devices, is necessary to ensure that the devices keep pace with (and do not hold back) the children's progress.

(k) Decentralized community-based production of assistive devices is one means of overcoming the difficulties of distribution to persons with disabilities in remote areas. This may be achieved through the widespread dissemination of knowledge and development of skills among persons with disabilities, members of their families, craftpersons, mechanics and welders. Certain types of assistive devices, e.g., hearing aids and braille slates, and certain materials, e.g., high density polyethylene and polypropylene, as well as components, e.g., knee joints and castor wheels, are amenable to large-scale production.

(l) Distribution of information on technologies and production processes, together with problem-solving skills, are as important as distribution of assistive devices per se. In situations where the production of assistive devices requires more sophisticated skills and/or costly production units, and to attain a synergy of efforts, it is important to promote networking and exchange of products, components and experiences, as well as training expertise.

D. Principles concerning specific devices

In addition to the general principles, the following are principles of particular relevance to some specific devices.

1. Prostheses and orthoses

1. Prosthetic and orthotic production principles:

   (i) The design of prostheses and orthoses shall conform to the principles of biomechanics and engineering drawing requirements;

   (ii) The costs of prostheses and orthoses shall be low enough to be affordable by the majority who need them;

   (iii) Prosthetic and orthotic production, repair and maintenance shall involve the use of easily available local materials;

   (iv) The prostheses and orthoses shall be acceptable to the users, who shall have assurance of quality;

   (v) Prosthetic and orthotic devices shall be easy to make, durable and light in weight;

   (vi) Prosthetic and orthotic repair and maintenance services shall be within easy reach of the users;

2. Prosthetic and orthotic distribution principles:

   (i) Rehabilitation centres, including workshops for the production and distribution of prosthetic and orthotic devices, may be decentralized;

   (ii) Proper follow-up services, particularly through community-based rehabilitation, may be organized.

2. Principles concerning devices for SCI persons

1. The training of medical and health professionals (e.g., doctors, nurses, occupational therapists [OTs] and physiotherapists [PTs]) to increase their knowledge and skills concerning proper treatment and rehabilitation of persons with SCI, including appropriate locomotor and self-care devices, is essential to the prevention of dangerous medical complications;
2. Experienced persons with SCI are the best teachers for newly-injured individuals to learn, in the absence of sensation, new ways of detecting subtle signs of body needs and functions, as well as the know-how to respond to them.

3. Principles concerning devices for persons with multiple disabilities, including persons with cerebral palsy (CP)

1. The rehabilitation of persons with multiple disabilities, including persons with cerebral palsy (CP), is a lengthy process involving a multidisciplinary approach, in which the persons themselves and their families play a central role;
2. Government and NGO development assistance, especially in the rural areas, must include support for enhancing the local production, modification, repair and maintenance of affordable and attractive devices needed by persons with multiple disabilities, including those with cerebral palsy (CP);
3. Illiterate and semi-literate parents and community members shall be made aware of existing resources for, and the benefits of, appropriate devices for persons with multiple disabilities;
4. The life situation and culture of persons with multiple disabilities shall be taken into consideration in the provision of the assistive devices.

4. Principles concerning devices for persons with low vision

1. Persons with low vision shall have the choice of using low vision devices or developing the skills to maximize their use of remaining vision;
2. The know-how for making low-cost low vision devices shall be shared and disseminated to facilitate the establishment of more optical workshops and training of technicians.

5. Principles concerning devices for persons with hearing impairment

1. In the production of hearing aids, the performance characteristics shall be carefully checked to enhance quality assurance and reduce dependence on costly infrastructure for reassessment, and repair;
2. Experienced users may be mobilized to provide guidance in the correct fitting of hearing aids, especially for children;
3. Distribution of hearing aids and listening devices shall take into consideration the unequal access, of hearing-impaired women and children, to devices, affordable battery cells, and repair and maintenance services.

E. General recommendations

Regional

1. Establish, using existing resources, a regional information centre, including a database, to collect and disseminate knowledge concerning assistive devices in the ESCAP region;
2. Create and improve inter-country linkages to strengthen training, as well as exchange of expertise and technical knowledge concerning devices for the poor, including through encouraging existing centres to contribute resources, to support regional rehabilitation technology training and research;
3. Support technical cooperation among developing countries (TCDC), to assist in:

   (i) Matching specific needs with available resources and expertise within the ESCAP region;

   
   

   (ii) Training engineers, technicians and community rehabilitation workers in production, assessment, distribution, fitting, and follow-up concerning low-cost and high-quality appropriate devices for the poor;

   
   

   (iii) Reducing the time lag between inventions and innovations, and their application in enhancing indigenous rehabilitation engineering;

National

4. Formulate a national plan for assistive devices;
5. Develop a roster of national experts on assistive devices;
6. Improve services, including transport connectivity, to the rural areas, especially in large countries of the region, where there is a lack of appropriate devices;
7. Strengthen rehabilitation services through, inter alia,:

   (i) Improved coordination among health care personnel, including medical doctors, surgeons, technicians, as well as community workers, persons with disabilities and their families;

   (ii) Greater emphasis on ensuring follow-up services and facilities for users of the devices;

8. Mobilize more resources for providing assistive devices to the poor, including through:

   (i) Funding and local government support;

   (ii) Improved conditions for indigenous research in, as well as innovation and development of, high-quality, low-cost devices which are appropriate for the large majority in the rural areas;

9. Introduce, in developing countries of the ESCAP region, modules and kits as reference materials for the indigenous production of assistive devices, and to facilitate, where feasible, some standardization of devices and delivery of services, to ensure quality for the poor;
10. Develop means of training more technicians in the production and distribution of assistive devices, with emphasis on training people with disabilities and their family members, as well as other local community members;
11. Include among the selection criteria for the training of rehabilitation workers and assistive device technicians affinity with local communities to be served, and likelihood of serving the local communities after training;
12. Initiate effective means of disseminating, within each country, indigenous knowledge concerning assistive devices, taking into consideration that word-of-mouth and the mass media are effective information channels;
13. Encourage the formation of parents' associations, to facilitate local production, as well as efficient use and maintenance of devices for children with disabilities;
14. Identify remunerative jobs for persons with disabilities, and provide them with appropriate devices and skills training for those jobs.

F. Recommendations concerning specific devices

1. Recommendations concerning prostheses and orthoses

1. Encourage coordination among government institutions, NGOs and the private sector in ESCAP developing countries, to promote the expansion of rehabilitation services for disabled persons, especially concerning the production and distribution of prostheses and orthoses;
2. Encourage indigenous production and minimize importation of prostheses and orthoses;
3. Compile and disseminate design drawings, and a directory of assistive devices containing, inter alia, important common features of prostheses an orthoses, for the information of other ESCAP members and associate members;
4. Standardize the in-country production of orthoses and prostheses, keeping in mind that each country has its own specific requirements and needs.

2. Recommendations concerning devices for persons with spinal cord injury (SCI)

1. Develop a network of rehabilitation centres and institutes for persons with SCI, to promote technical cooperation among developing countries (TCDC), particularly involving different community programmes and institutions, to exchange information and techniques on the rehabilitation of persons with SCI;
2. Encourage a centre in a developing country of the ESCAP region to serve as a regional focal point for research on indigenous techniques and devices for the health maintenance and integration into society of persons with SCI;
3. Examine ways of using established financial (e.g., subsidy, micro credit and loan) schemes to enable all non-ambulatory poor persons with disabilities to acquire wheelchairs, tricycles, trolleys or other assistive devices required by them;
4. Support the development of self-help groups of persons with SCI, to provide newly-injured persons with peer support and counselling, as well as good role models;
5. Disseminate technical information on standing frames, and other devices for persons with mobility difficulties, to enable carpenters and craftpersons in local communities to produce those devices;
6. Encourage local development of low-cost bladder control techniques and devices for persons with SCI, with emphasis on the need for adaptation of techniques and devices to the specific needs of the individual who may have a spastic or flaccid bladder, as well as a good quantity of urine left in the bladder after voiding;
7. Disseminate widely information on bladder control techniques and devices to persons with SCI, their families and those who work with them;
8. Develop local production of low-cost and high-quality wheelchair cushions, using locally available materials, to prevent pressure sores.

3. Recommendations concerning devices for persons with multiple disabilities, including cerebral palsy (CP)

1. Use existing channels of information, communication and education directed at poor communities to conduct a sustained information and community awareness programme on the variety of assistive devices which can be locally produced to benefit persons with multiple disabilities, including cerebral palsy (CP);
2. Train community-based and multi-purpose rehabilitation workers to:

   (i) Correctly assess needs for, as well as fit assistive devices and evaluate their relevance;

   (ii) Undertake, in close consultation with users and parents (in the case of children with multiple disabilities) proper assessment for, as well as the fitting and evaluation of assistive devices, to determine the appropriateness and usefulness of such devices for the users;

   (iii) Conduct follow-up as regularly and frequently as required, to ascertain if the assistive devices are being used properly as well as to provide the necessary support and encouragement;

3. Train parents, teachers and other persons interacting regularly with persons with CP, including persons with disabilities, on the proper techniques and use of devices, as well as respect for user views on comfort and adjustments to facilitate use.

4. Recommendations concerning devices for persons with visual impairments

1. Disseminate the know-how for indigenous production of low-cost low vision devices and expand the training of technicians, to enhance the availability of affordable low vision devices in the developing countries of the region;
2. Inventorize indigenously produced assistive devices for persons with visual impairments;
3. Identify national resources for augmenting the indigenous production of assistive devices for persons with visual impairments;
4. Establish linkages between centres for eye care, primary eye care programmes, and institutions, centres and programmes which meet the education, training and social needs of disadvantaged groups, among whom are persons with low vision, to enhance low vision training, assessment, referral, distribution of devices, and follow-up;
5. Train community workers, teachers, health workers and persons with residual vision, to develop skills in maximizing the use of remaining vision.

5. Recommendations concerning devices for persons with hearing impairments

1. Develop inter-country cooperation on the indigenous production of receivers for hearing aids;
2. Encourage the development of a national plan for assistive devices, which includes devices for persons with hearing impairments, and, if feasible, the indigenous production of receivers for hearing aids and ear moulds;
3. Develop effective information exchanges between community-level hearing aid users and national and subnational NGOs, and institutions, including those for rehabilitation engineering;
4. Train personnel and increase facilities for the correct fitting of hearing aids through one-on-one hearing aid trials and use of computerized techniques;
5. Identify local coordinators, who may be hearing-impaired persons or their family members, to participate in training and to monitor services for hearing-impaired persons;
6. Introduce, in the production process, measures to closely monitor the performance characteristics of hearing aids;
7. Explore the possibility of introducing digital-technology hearing aids in relation to existing technology in the context of individual developing countries of the region.

VI. Adoption of the Report

The participants adopted the report of the workshop, including the recommendations, as amended, on 14 September 1995.

VII. Closing of the Workshop

The Joint Secretary (Handicapped Welfare), Government of India, and the Secretary (Social Welfare and Nutritious Meal Programme), Government of the State of Tamil Nadu, attended the closing of the workshop. The participants expressed their commitment to individual and collective follow-up action to expand national capacity for and strengthen regional cooperation on the indigenous production and distribution of assistive devices, particularly for the poor.

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ECONOMIC AND SOCIAL COMMISSION FOR ASIA AND THE PACIFIC
Production and distribution of assistive devices for people with disabilities: Part 2
- Report of the technical workshop -

ST/ESCAP/1774

UNITED NATIONS PUBLICATION
Sales No. E.98.II.F.7
Copyright © United Nations 1997
ISBN: 92-1-119775-9