Growing O&P in Developing Countries

By Linda M. Hellow

O&P nongovernmental organizations (NGOs) in developing countries don't just fit and fabricate devices. They stimulate local economies, promote healthcare infrastructure, and empower people with disabilities.

Waag Society, Amsterdam, Netherlands, is networking with House of Natural Fibers (HONF) in Yogyakarta, Indonesia, on its design. Both businesses are FabLabs and part of a global network of 125 high-tech labs that could become manufacturing sites for the design. Photograph courtesy of Waag Society.

Scanio makes a cast for a young patient's AFO during a clinic he runs once a year at Children's Rehabilitative Hospital, Guatemala City. Photograph courtesy of FOOT Foundation.

Humanitarian groups providing O&P care in developing countries cope with many challenges-rough roads, unreliable electricity, inadequate health and education systems, and patients who don't have enough to eat, let alone the means to pay for a prosthesis. Yet the need is crushing. About 30 million people in Africa, Asia, and Latin America need O&P care, according to statistics cited in the 2011 "World Report on Disability," coproduced by the World Health Organization (WHO) and the World Bank. Most of these individuals are unable to acquire assistive devices, which impacts their ability to get an education and employment. Consequently, they tend to be among the poorest people in their communities.

Working with Local Economies

Dino Scanio, CO, LO, Pediatric Orthotics and Prosthetics Services of Tampa, Florida, serves pediatric patients in Guatemala City, Guatemala, through the Florida O&P Outreach Team (FOOT) Foundation, which he and his wife, Lisa, founded in 2007. When he can, he supplies local practitioners with components so they can, in turn, help their poorest patients. "One prosthetist I work with takes care of patients in his living room," Scanio says. "In addition to providing care, he cooks for the families because they don't have enough money to buy food. As it is, they are saving money so they can pay him for the care. [He's] the kind of guy who will say, 'Only give me half. Go take care of your family.'"

This economic reality underscores other challenges aid groups face and has led to policies that don't just fill the need for today, but build self-sufficiency for tomorrow. For more than 30 years, WHO and the International Committee of the Red Cross (ICRC) have emphasized the need for aid organizations to involve local communities in ways that build economies. In 2009, the U.S. Member Society of the International Society for Prosthetics and Orthotics (US ISPO) supported this approach when it asked O&P NGOs to sign a Code of Conduct that encourages "local capacity for providing prosthetic and orthotic and mobility services" and to use "existing local service providers." To date, 14 organizations have signed.

Mary Kwasniewski, senior director of global health programs for Physicians for Peace, chairs the International Society for Prosthetics and Orthotics (ISPO) International Outreach Committee and says the code sets a standard for groups delivering aid and an expectation for those receiving it. The committee is presently seeking feedback on the Code of Conduct, which is available on US ISPO's website.

"The bigger picture is: You need a prosthetic device for life, and so those services can't just be flown in and flown out one time a year," Kwasniewski says. "So how do we work with the local facilities, the local ministries of health, [and] the local clinics to make sure their capacity is being built so patients can be seen year-round? Then, how do we also make sure they are trained to an international standard...and do it all for a low cost?"

Jon Batzdorff, CPO, chairman of US ISPO, is president of ProsthetiKa, an NGO serving in Haiti, Mexico, and Bolivia. "Our strategy is to work with locals and not just for locals," Batzdorff says. "In other words, we partner with local practitioners to deliver services to patients who are indigent and could not otherwise receive services. ProsthetiKa can participate in several ways depending on the specific needs: providing training or technical assistance and, at times, components and tools to the local practitioners."

In Haiti, ProsthetiKa provided the necessary training to set up an O&P clinic at a local hospital. Now four local staff members do all the hands-on work.

"We also work in a similar way in Mexico and Bolivia," Batzdorff says, "being equally careful where we work and with whom."

Some of the individuals Batzdorff works with come from the disabled community. For example, in the rural region of Sinaloa, Mexico, ProsthetiKa partners with the established Program of Rehabilitation Organized by Disabled Youth of Western Mexico (PROJIMA), which is run by people with disabilities. Batzdorff and his crew train them to make and fit prostheses, orthopedic braces, and wheelchairs.

FOOT Foundation also makes an effort to support the local O&P practitioners in private practice through its payment program. The patients Scanio sees are selected by social workers at the hospital who prescreen their ability to pay. Scanio only takes those patients for whom payment would be a hardship.

Mobility Outreach International uses a simple but durable mono-limb design for patients living in rural areas far from the clinic. Photograph courtesy of Mobility Outreach International.

"We follow a humanitarian sliding scale," he explains. "If they have a certain number of dollars, I can slide them over to the private sector and keep the wealth within the local community. They're supporting their own industry, their own community. Now, the family that lives in a clay hut, they're going to come to my clinic where everything they get is 100 percent free."

Supporting Manufacturing

The goal of self-sufficiency is also being nurtured in countries with more developed manufacturing capacity. Mobility Outreach International (MOI), formerly Prosthetics Outreach Foundation, made significant strides in Vietnam where it now only offers assistance via consulting. But it takes time, says Raymond Pye, MOI director of program quality and emerging programs. MOI was in Vietnam for 20 years working alongside existing government healthcare institutions, waiting and watching as the country's government and industry developed the capacity to fully manufacture O&P devices and deliver high-quality O&P care.

Much of the early effort in Vietnam, and everywhere else MOI goes, Pye says, was directed toward building relationships with local government and industry. The first thing he does, before MOI puts people on the ground, is to study the local manufacturing. "We develop connections with other industries that have similar processes and materials," says Pye, who has a bachelor's degree in industrial design. "A lot of materials used for making prostheses are also used in shoemaking-the soft foam, the molding equipment for making shoe soles. We can get a lot of information and hopefully materials from those factories. Initially, you're treated as someone who's just annoying. It is a factory that is into production and we're looking for help with low-volume products.... So the trick is to develop a relationship with someone inside the factory and ask them to be compassionate."

Waag Society and HONF are testing locally abundant plant fibers for use in socket fabrication. Photograph courtesy of Waag Society.

Scanio says since FOOT Foundation is relatively young, he needs more time and resources to build relationships with the manufacturing sector. Once a year, he takes a team of four or five O&P professionals to Guatemala City with donations of appropriate new and used O&P components. He is also looking to have his patients donate their devices back to the program when they outgrow them. He has, however, invested ample energy into relationships with the local practitioners and hospital professionals who provide follow-up care.

"My clinic has been going for seven years, and it's taken me that long to get the kind of relationship I have now with the government, with the hospital, with the doctors, and [with] the local practitioners," he says. "If you have strong relationships, you're going to have the backing of the people and the country, and you're going to do a greater good."

Fabrication from Local Resources

While NGOs work to develop relationships and, in many cases, while they wait for a country's manufacturing sector to grow, they adapt devices so they can be fabricated using local raw materials and tap into local supply chains for the imported goods they need. The necessity to be creative with materials, as well as to fabricate low-cost devices that will withstand such things as harsh environmental conditions, barefoot walking, and frequent kneeling, have also led to some innovative designs. What follows are a few of the innovations being used or in development.

Waag Society is testing a low-cost and adjustable design it built from local raw materials, such as bamboo and pineapple fiber, in Indonesia. Photograph courtesy of Waag Society.

Low-Cost Prosthesis: Low cost and durability are the two basic requirements for the prosthesis that Waag Society's Fablab, Amsterdam, Netherlands, is developing, says manager Alex Schaub. Schaub is working with another Fab Lab, House of Natural Fibers (HONF) in Yogyakarta, Indonesia, to produce a transtibial prosthesis from local fibers for US $50. HONF's project is testing locally abundant bamboo and pineapple fiber for the socket, as well as a self-adjusting component to minimize the need for rural patients to travel for follow-up adjustments. By using a network of more than 125 Fab Labs (organized by the Massachusetts Institute of Technology, Cambridge) around the world, Schaub says they can develop one design that can be modified to use each Fab Lab's local materials. Patients could even be involved in making their own limbs, further empowering the patients, and creating ownership.

Sustainable Casting Method: Yeongchi Wu, MD, a research associate professor in physical medicine and rehabilitation at Northwestern University Prosthetics-Orthotics Center (NUPOC), Chicago, Illinois, developed a casting system that does not use plaster, which can be difficult to find in some countries. His method uses polystyrene beads as the casting material for prostheses, and recently he adapted the method for the fabrication of orthoses. The advantage of polystyrene beads, Wu says, is that they are lightweight, long lasting, and reusable. The residual limb is simply placed in the casting bag with the beads, and vacuum is applied to form the negative mold. Wu says his method has been used mostly in Thailand, India, and Africa for prosthetic socket fabrication. Clean sand can be used if there is difficulty finding polystyrene beads in small quantities.

Jaipur Foot and Stanford-Jaipur Knee: Bhagwan Mahaveer Viklang Sahayata Samiti (BMVSS), Jaipur, Rajasthan, India, is an NGO that is well known for its low-cost, durable polyurethane foot-the Jaipur Foot. It is a non-articulated foot that provides mobility in all three planes of motion and can be used with or without shoes. D.R. Mehta, founder of BMVSS, and the BMVSS team have also developed a prosthetic knee with researchers at Stanford University, California. The Stanford- Jaipur Knee provides stance phase stability and swing phase response. Mehta says the cost of the knee, foot, and shank averages US $50 but is provided by BMVSS at no cost to patients who attend any of its 22 walk-in clinics in India, or who come to a Fitment Camp in one of 26 countries in Asia, Africa, and Latin America. All components are manufactured in India.

P&O in India

Left: In India, patients have access to Bhagwan Mahaveer Viklang Sahayata Samiti (BMVSS) clinics where a prosthesis is free, allowing patients the mobility they need to work and play, regardless of their ability to pay. Right: The average cost of a Jaipur transfemoral prosthesis is US $50. Photographs courtesy of BMVSS.

Designs Adapted for Locations: Pye says MOI's prosthetic designs vary depending on the materials available and where patients live. In the West African nation of Sierra Leone, for example, MOI uses a mono-limb design that is durable and inexpensive. The design is basically an extended socket with a foot attached by just one bolt; there is no separate pylon. "You're basically making the entire prosthesis out of the same piece of plastic that you would use for the socket," Pye says. "It's not perfect, but it's a way to make a much cheaper leg that is very durable.... This is a big advantage in these remote areas [where it's difficult to reach people for repairs and adjustments], because we know we have a good connection between the foot and bolt." Everything Pye needs to make this prosthesis is available locally except the plastic. MOI prefers to purchase a blend of polypropylene and polyethylene that is imported from Scotland.

Locally Resourced Footwear: Dennis Janisse, CPed, president and CEO of National Pedorthic Services, headquartered in Milwaukee, Wisconsin, has researched the use of local resources to fabricate low-cost sandals to alleviate common foot pathologies in developing countries. Working with Legs to Stand On (LTSO), Janisse has been to Ghana where diseases such as diabetes, elephantiasis, leprosy, and Buruli ulcer often lead to limb impairment and amputation. The World Diabetes Foundation notes that 40 to 70 percent of all lower-limb amputations in the world are related to diabetes, and 85 percent of all diabetes-related foot and leg amputations begin with a foot ulcer. Janisse says that providing sandals to individuals in less-resourced environments could play a role in preventing some of the worst outcomes from these diseases. The sandal is made from materials he found in the local markets: inner tubes from old tires make the straps, and ethylene-vinyl acetate (EVA) thermoplastic forms the soles. "You can go to the markets and there are vendors that supply shoe repairmen," he says. "So you can get EVA, buckles, rivets, and contact cement."

To ensure the program's sustainability, LTSO aims to develop small retail footwear businesses in two rural villages. "We would give them what they need to start...[and] they'd sell the sandals for $7 to $8 a pair. The materials cost about $3 or $4. So if a few people started making them, there would be some profit, and they could buy materials to keep it going."

The initial phase of the sandal project is to just get people making sandals, Janisse says. "The secondary goal is to work with the local doctors on the therapeutic aspect," he says. "We'd provide training so that if, for example, they've got an ulcer on a metatarsal head, they would be able to put a rocker sole on that sandal to relieve pressure."

(Editor's note: Both Waag Society and LTSO projects are waiting for further funding.)

Meeting the Education Challenge

ISPO, in close collaboration with WHO, has developed education and training guidelines for three levels of O&P services: Category I, a professional prosthetist/orthotist; Category II, an orthopedic (prosthetics, orthotics, or spinal orthotics) technologist; and Category III, an orthopedic technician/bench worker. According to WHO, in 2005 there were 24 O&P schools in developing countries that use these definitions in their educational structure. Together, they graduate just 400 people annually-certainly not enough to meet the needs of 30 million patients.

To meet the educational gap, Scanio and Batzdorff say that when they are on-site, they do more than just fit patients. They train and educate the local practitioners and the patients, as well.

"Our projects are 100 percent training projects," Batzdorff says, "though it is on-the-job training in which we work hand-in-hand with the local practitioners. In Haiti, for example, one technician trainee is also enrolled in an ISPO Category II training program to...[receive] formal training, while we provide the clinical and technical experience."

Pye says MOI hires at least one Category II prosthetic technologist in each of its workshops. But, as with the MOI program in Sierra Leone, that person can be difficult to find. "In Sierra Leone there are only eight Category II guys in the whole country," he says. "The rest are bench technicians like Category III, or locally trained technicians who have a lot experience, but they don't have much formal education."

For citizens of Sierra Leone to earn a four-year degree in O&P means traveling more than 3,000 miles to attend the Tanzania Training Centre for Orthopaedic Technologists (TATCOT), Moshi, an ISPO-accredited school.

Providing Jobs

Kwasniewski notes that, depending on the country, most trained prosthetists, orthotists, and technicians are paid by privately run clinics or NGOs. In general, governments don't have services for disabilities, let alone individuals with amputations. "That's changing," she says. "Recognizing people with disabilities as a group that needs services is definitely changing. But it doesn't get the funding that malaria does, nor maternal and child health."

MOI has been training local technicians in Makeni, Sierra Leone, since 2005, while working with the Ministry of Health and Sanitation to establish a prosthetics center at Makeni Government Hospital. After 11 years of civil war, the government struggles to provide salaries, so MOI is currently paying a monthly stipend to the O&P employees until the government budget includes hiring more O&P staff. However, Pye says MOI is keenly aware that the government pay scales are less than what NGOs typically pay.

"It's a problem," Pye says, "because NGOs want to pay a wage that reflects a person's training according to our standards. But it's not that simple if there will be a sudden decrease in pay once we transition all operations to the government."

Kwasniewski agrees that appropriate pay for those who have the training is one of the biggest challenges right now. "We can train all the prosthetists in the world, but if they don't have anywhere to work, it's not going to do any of us any good.... We have to ask, 'What are the job opportunities once they're trained? Can they be employed by local facilities? Is there infrastructure in place for them to be paid a living wage?'"

When all the pieces come together, jobs are created, local economies are stimulated, and people with disabilities are empowered. Kwasniewski offers an example of a patient who received a prosthesis at a clinic in Manila, Philippines, and then sought training so he could work in a new clinic that Physicians for Peace was providing start-up funds for in his home province of Pampanga, Philippines.

"It was full circle and empowering to have someone who now has a prosthesis say, 'Hey, I don't want to have to come in to Manila for this kind of service. What can we set up where I live in Pampanga, and can I be the technician?' It was an area where we wanted to expand, but he definitely took the initiative to say, 'Well, why don't you train me? You're going to have to train someone; why not train me?'"

Linda M. Hellow is a freelance writer based in Centennial, Colorado. She can be reached at