Sustainable and equitable provision of wheelchairs in low- and middle-income countries: an economic assessment of the models for wheelchair provision in Tajikistan
Introduction
Reaching universal coverage of assistive technologies remains a challenge in many low- and middle-income countries. Tajikistan has recently adopted several policies and national strategies to strengthen the rights of people with disabilities and improve the provision of assistive products. However, Tajikistan faces a number of challenges, including ensuring sustainable funding for the provision of wheelchairs in the medium and long term.
Methods
This study presents the results of a recent analysis of the economic aspects of the provision of wheelchairs in Tajikistan to inform policy making in other low- and middle-income countries. The study draws on several sources of information, including local cost data, consultations with national and international experts and stakeholders, and reviews of the existing evidence.
Results
Countries are advised to adopt an incremental approach to wheelchair provision. In the short term, countries may wish to import wheelchairs to move towards universal coverage. In the medium-to-long term, countries may wish to invest in national capacities for local production.
Conclusion
Countries will need to continue implementing strategies to ensure universal access to wheelchairs without the risk of financial hardship for users, regardless of the approach to provision that has been chosen.
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Implication for Rehabilitation
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Reaching universal coverage of assistive technologies remains a challenge in many low- and middle-income countries.
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Countries are advised to adopt an incremental approach to wheelchair provision.
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The model of wheelchair importation may be a realistic model over the short- to medium-term for many LMICs countries to ensure effective and equitable provision of wheelchairs.
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In this article, we identify that sufficient funding needs to be allocated to the provision of wheelchairs regardless of the model of provision.
In the past decade, global efforts to ensure universal access to assistive products for improving the lives of people with disabilities and ageing population have significantly advanced. This includes the World Health Organisation (WHO) resolution on assistive technology and the launch of a global partnership for assistive technology (Citation1,Citation2). There is now broad agreement on the need for these technologies and services in efforts to reach universal health coverage (UHC) in line with the sustainable development goals (SDG) (Citation3). The efforts to ensure access to assistive products are reflected in policy changes in individual countries and there are several examples of successful strategies that have been implemented; for example, the adoption of the first priority assistive product lists in Tajikistan (Citation4) and Nepal (Citation5). However, in many low- and middle-income countries (LMICs), challenges to the sustainable and broad-based provision of assistive technologies remain, including for the provision of wheelchairs (Citation3).
Tajikistan’s economic and social situation
Tajikistan is a low-income country with a total population of approximately 9 million, approximately half of whom are children and adolescents. The average annual per capita income is approximately US$812 (Citation6,Citation7). Tajikistan’s recent overall macroeconomic performance has been relatively favourable (Citation8,Citation9), with economic growth remaining at 6–7% per year since 2010, resulting in a fairly high per capita growth rate during this period. While the government retains a fiscal surplus of approximately 1% of GDP, the health budget is limited (Citation10).
Tajikistan has high rates of literacy, school enrolment and school completion. Access to clean water and sanitation has improved over the past decade. However, malnutrition is prevalent, particularly in rural areas. Immunisation rates against key childhood diseases are high, but life expectancy is low at 69 years and 73 years for men and women, respectively (Citation11).
Approximately 30% of people live below the official national poverty line, and there is a high level of extreme poverty (17%). Poverty is more prevalent in rural areas where the overall poverty rate was 36% in 2014 (Citation12). Tajikistan has relatively weak social targeting programmes (Citation6), despite the existence of formal programmes designed to provide financial support for vulnerable population groups (Citation13).
Wheelchair provision in Tajikistan
This sub-section describes the current status of the provision of wheelchairs in Tajikistan. It is based on a recent investigation by a team of researchers working with national and international experts and policy makers to review key aspects of the provision system and how it has evolved over the past few years.
Government provision
The prevalence and nature of disability in Tajikistan is not well documented (Citation14); however, estimates suggest that between 60 000 and 90 000 people need wheelchairs for everyday use (Citation1,Citation15). Tajikistan imports around 800 wheelchairs per year, and a small number are assembled or produced by local manufacturers. However, the number of wheelchairs currently being supplied is insufficient, as the need for wheelchairs exceeds an estimated 11 700, annually (Citation16). The Tajikistan government has recently adopted a series of policies and strategies to improve wheelchairs provision, including the National Programme on Rehabilitation of Persons with Disabilities 2017–2020 (Citation17). This programme also includes an action plan for more widespread provisions of assistive devices. Tajikistan signed the UN Convention of the Rights of People with Disabilities in 2018, an important step in the countries’ commitment to access assistive products, such as wheelchairs, for people with disabilities.
The Tajikistan government does have a programme of wheelchair provision, but it has several shortcomings, and public awareness of how to obtain a government provided wheelchair appears to be low (Citation10,Citation18). The government imports approximately 800 wheelchairs per year from China at a price of US$77 per unit plus US$32.50 for transportation from China to Dushanbe. The wheelchairs then have to be distributed to users around Tajikistan from the central warehouse in Dushanbe (Citation19). Price is the main selection criterion for wheelchair purchases, and little consideration has been given to quality or design (Citation10).
Other provision
A limited number of wheelchairs are currently supplied through donations. Between 2015 and 2018, International non-governmental organisations donated over 700 wheelchairs of different models to Tajikistan (Citation10). Additionally, Tajikistan has two small-scale producers of wheelchairs. However, these producers have produced fewer than 150 wheelchairs since 2015 and their operations have effectively stopped (Citation10).
Assessment of current wheelchair provision
Based on the recent investigation, including interviews with national experts and users of wheelchairs, this sub-section assesses the current situation along key policy and operational aspects. The wheelchairs imported by the government are not appropriate for active users who can propel their own wheelchairs without any assistance, or for children or users who require postural support (Citation10). Complaints by users include poor quality, low manoeuvrability, and that the wheelchairs are difficult to transport (Citation10). In a recent survey, users estimate that the maximum working life of the imported wheelchairs is under one year, which is well below the expected lifetime according to international standards (Citation18).
Additionally, there are limited funds for the services needed for effective and sustainable wheelchair provision, including referral, fitting, training and repairs (Citation18). The investigation also found that Tajikistan has very few personnel who are trained in wheelchair provision, and the skills of the existing workforce are limited or outdated, resulting in many people being given the wrong type of wheelchair or an incorrect size (Citation14,Citation18). Incorrect provision of wheelchairs limits their usefulness and contributes to abandonment and underutilisation of wheelchairs, and to the risk of injuries. Wheelchair users and their families are obliged to fund the maintenance and repairs themselves which adds an additional financial strain to families (Citation14).
While the Tajikistan government has introduced services to improve the situation, these are not fully funded or organised in a sustainable manner (Citation18). A few basic-level training events on wheelchair provision, supported by WHO, have been conducted over the past few years (Citation20).
Wheelchair provision models
In order to assess the viability of different options that Tajikistan might choose for developing its capacity to supply wheelchairs to all those who need them, three main models (or approaches) have been studied (Citation10). There are the three main models of wheelchair provision that countries may adopt: (1) importing complete wheelchairs; (2) importing components for local assembly; (3) and local manufacture (Citation21) (). Understanding the advantages and disadvantages of each model is critical for making policy choices; however, in practice, an optimal policy mix is often achieved by combining these different approaches (Citation23,Citation24).