Background and Need
It has been widely documented that when a person’s life is impacted by impairment, he/she is more likely to experience poverty, poor health, and limits in community participation. These issues should be addressed as core priorities in the development of national level policies and programs [1-4]. For many people with a mobility impairment, access to an appropriate wheelchair is one of the most effective steps to equality of opportunity to access basic human rights and moving beyond survival towards active participation [5]. Access to appropriate wheelchairs for those who need them is a basic human right [6]. Wheelchairs are an essential assistive product device [7], providing a personal posture and mobility support system, which enhances an individual’s physical, physiological and psychological health and wellbeing [8]. Wheelchairs enable equality of opportunity to access education, employment and community, and healthy aging for older people that need them, when provided with appropriate healthcare and social care supports, along with emergency backup services, in line with the requirements set out by the global disability rights movement and the United Nations Convention on the Rights of Persons with Disabilities [6, 9-12]. Effective wheelchair provision can reduce healthcare costs, and as mentioned previously, facilitate that people with disabilities access education and employment, and increase their overall quality of life [13, 14].
Through efforts by the World Health Organization (WHO), the United States Agency for International Development (USAID), and pivotal organizations that have been working in the wheelchair sector for over 20 years, there has been critical material generated that highlights the need not only for an appropriate wheelchair but also the recommended processes by which wheelchair service users can access a wheelchair and adequate follow-up supports. For instance, the WHO Guidelines on the Provision of Manual Wheelchairs in Less-Resourced Settings (WHO Guidelines) were developed with the involvement and inclusion of more than 100 wheelchair sector stakeholders from all over the world and represents one of the most important international instruments that is specifically focused on issues of wheelchair provision [5].
The WHO Guidelines outline the key framework for appropriate wheelchair provision that is used to support improvements in the wheelchair sector internationally.
The WHO Guidelines define an appropriate wheelchair as follows [5]:
– Meets the user’s needs and environmental conditions;
– Provides proper fit and postural support;
– Is safe and durable;
– Is available in the country; and
– Can be obtained and maintained and services sustained in the country at an affordable cost.
Moreover, the WHO Guidelines recommend that wheelchairs be provided through eight service delivery steps [5]:
1. Referral: A person with a mobility impairment is identified and referred to a wheelchair service. The individual, community services, and health or rehabilitation services can do referrals.
2. Assessment: Trained professionals conduct a comprehensive interview and physical assessment to understand the individual’s needs and objectives with the new wheelchair.
3. Prescription (product selection): The trained professional, in conjunction with the individual and his/her family, select the best available product that meets the needs and objectives identified in step 2.
4. Funding and ordering: An order for the selected product and the funding for it are put in place.
5. Product preparation: The product is assembled, checked for proper working conditions, and prepared accordingly to the individual needs.
6. Fitting: The prepared product is presented to the individual and checked for proper fit. Modifications must be done to meet the individual’s needs accordingly.
7. User training: The individual and his/her family are trained on how to use the wheelchair (e.g., handling and mobility skills), how to take care of it at home, and what to do if a problem is identified.
8. Follow up, Maintenance, and Repairs: All wheelchair users must be followed up to check that the product continues to meet his/her needs appropriately. In addition, maintenance and repair services must be available to the individual in case problems arise.
The provision of an appropriate wheelchair using the WHO 8 steps, which when followed can prevent additional health complications (e.g. pressure injuries, postural deformity, mental health issues), and abandonment of assistive technology. Complexities of access to an appropriate wheelchair can be understood when considering the assistive technology provision ecosystem, which includes technology, social, financial, governmental, private business and health care systems [8, 15, 16]. As illustrated in
Figure 1, there are a number of different government agencies that may be required to work together cohesively for effective change in wheelchair provision, focusing on interconnecting processes to achieve sustainable wheelchair provision systems through Access to Services, Assessment and Delivery, Funding Schemes, Education, Training and Research, Product development and Procurement. Policies impact each step of this process. It is important to note that
Figure 1 is an example, and each country will have its own context-specific structure. Quite often, however, wheelchairs fall under either the ministry of welfare or health, without specific policies or clear structures governing wheelchair service provision [17]. Inconsistencies lead to ad hoc provision resulting in a lack of actions on the importance of developing sustainable policies and services[18, 19]. As a result, non-governmental organizations like Motivation, Whirlwind Wheelchair, and United Cerebral Palsy Wheels for Humanity, among others, often fill the gap for provision of an appropriate wheelchair.
Representation of core areas that need to be addressed to support sustainable wheelchair provision along with the responsible ministries /departments.
The PAK supports stakeholders with a framework and tools to address unmet obligations of the UNCRPD, focuses specifically on Article 20 (shown below), placing the wheelchair users as the central focus within the wheelchair provision process. The PAK is rooted in the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) [6], the World Health Organization (WHO) Guidelines [5] including the associated Wheelchair Service Training Packages (WHO-WSTPs)[20-23], and the International Standards for wheelchair and seating technology [24]. This PAK is especially important for member States who have ratified the UNCRPD, for whom promoting the right to personal mobility is a legal obligation.