Prótesis Imbabura: A Case Study on Sustainability in Ecuador
March 2019 Issue
When I walked into Prótesis Imbabura Clinic, I saw Ecuadorian O&P clinicians Gabriela Dávila fitting AFOs on triplets with muscular dystrophy and Jairo Collaguazo giving an O&P lecture to a group of physical therapy students from the local university. Dávila and Collaguazo are PTs who trained and completed O&P residencies with Robert Frank, CPO(E). I'm on my third trip to Ecuador, visiting Robert and his wife Kit Frank, OTR, the founders of Prótesis Imbabura, who built the clinic through their nonprofit, Fundación Jen Lee. Kit Frank's occupational therapy work complements the clinic's O&P services. The Franks are deserving of recognition and support, not only for their dedication and hard work, but for the model of sustainability and efficiency of their clinic. They have been coming to Ecuador to teach and to fit prostheses and adaptability equipment for almost 30 years.
After Haiti's devastating earthquake in 2010, I volunteered at a trauma hospital there and came away disheartened, not because of what I saw at the hospital, but at how little was being done with billions of dollars in international aid. My impression was of a disproportionate number of dollars going to expensive dinners and new SUVs instead of helping the people living in flooded tents. I decided after Haiti that I would focus on efficiency and sustainability in my professional efforts, working to achieve lasting impact with conserved resources and less overhead. I resolved that my work with nonprofit agencies would be restricted to working with people and groups with a demonstrated priority for mission accomplishment and conservation of resources. Nonprofits use the word sustainability a lot, but they are often run more like businesses that only want to stay in business. I believe their efforts stray from the goal of long-term problem-solving and settle for, or perhaps even focus on, just "helping," which often brings unintended negative consequences.
So, it was refreshing when the Franks welcomed me to their clinic in Ibarra, Ecuador, a bit north of Quito, and showed me their plan to work themselves out of a job. They have an open-book policy and were willing to show me every dollar spent. There is no formal O&P training program in Ecuador, and those working in our profession are either self-taught, learned on the job, received education abroad, or are foreigners. The Franks created O&P residencies for PT students to teach these skills. The foundation's supporting business, Prótesis Imbabura, is mostly self-sufficient and runs smoothly when the Franks are not there. The local Ecuadorian employees are owners of the clinic and have invested their time and wages to recently purchase a new clinic building. Fundación Jen Lee provides funding for expensive componentry otherwise unavailable to local patients. The Franks look for partnerships with local providers and other organizations to provide more value for the Ecuadorian people. The clinic fits about 35 new patients each month with custom devices and sees patients for follow-up visits and adjustments. The average cost to patients for the devices is about $150, a fraction of what custom fittings cost elsewhere in the country. The Franks and their foundation are constantly working to transition from donations into sustainable business models and micro-business ventures.
Kit Frank has also built a clinic where she and Alicia Rivadeneira, an adaptive equipment technician, build specialty seating and standing frames using a technique developed by the Adaptive Design Association. Laminated cardboard is used for standing tables, positioning devices, seat trays, and wheelchair adaptions. Kit Frank and Rivadeneira have led workshops in local communities where parents and family members could create equipment in a social setting.
A few of the Franks' projects in which I have participated are as follows:
Spina bifida educational materials. Kit Frank has partnered with the Spina Bifida Center and ARISE Adaptive Design in upstate New York to create bilingual educational materials that address the complex needs of families living with that disability and to share designs for adaptive equipment. The materials are used to educate local doctors and therapists so patients can be fitted with affordable adaptable equipment. With my fiancée doing the translation into Spanish, I called upon my own experience writing educational materials to help rewrite established spina bifida treatment guidelines into an easier to understand, local guide incorporating available local resources.
Designing and testing equipment. During and following a previous visit to the Franks' clinic, I spent several months prototyping silicone liners for fabrication in South America. Although this project has gone on the back burner for me due to time constraints, I'm hopeful I can return to it with the right partners in the future. The Franks have worked with medical professionals, designers, artists, students, and engineers on a number of design projects, one of which involved designing and ISO testing gait trainers, releasing the open-source designs on their website so anyone can make the device. That project was supported by the Rotary International Global Grant with the belief that "all children regardless of level of disability deserve the opportunity to get up and move around, to participate, to stand at the level of their peers, to develop their motor skills, and to experience moving under their own power." Roberto Ulluari, a local artisan and designer in Quito, has a micro-enterprise called Pro-Movilidad that uses the designs to build the gait trainers for his community, manufacturing a customized version for 25 percent of the cost of off-the-shelf U.S. designs.
Ruedas Sin Fronteras. On my last trip, I observed the start of one of the Franks' newest efforts—working with the Ibarra wheelchair basketball team Ruedas Sin Fronteras, or Wheels Without Borders. Although they dream of playing other teams, their current wheelchairs are not approved for use in any of the wheelchair basketball leagues, and none of the chairs provide the stability, speed, and safety needed to compete. Many of the chairs were in poor condition, missing pieces such as footrests or with damaged wheels and casters. The team does not have access to any shops to build, repair, or customize wheelchairs. During the game I watched, there was a delay because one of the chairs broke and had to be fixed. After filming and photographing the match, my fiancée and I created a video for publicity and fundraising purposes. Fundación Jen Lee is working to fund wheelchairs for the team, and if funding can be found, perhaps even build and equip a shop where the team can run a wheelchair construction and repair business.
Potential volunteers and people considering starting a nonprofit should consider the following:
To provide the most help to those in need and optimize your own efforts, look for activities that are transparent with respect to funding and volunteer labor and that have a well-conceived model for delivery of services. Anticipate how your volunteer hours and dollars will be used and who benefits the most. If you are fitting someone through an operation with no locally trained and available technicians to provide follow-up, the effort is probably not sustainable and there may be better volunteer opportunities. And if you think you might want to start your own nonprofit clinic, a pivotal portion of your efforts should be spent on education. Sustainability is also supported by getting local people personally invested through contributed labor and partial financial ownership within the business model.
While the Franks have chosen to volunteer their time without pay, this is obviously not feasible for every nonprofit venture. It does not, however, change the need for efficiency and transparency. For the Franks, it certainly allowed them to reach a sustainable model more quickly. One hundred percent of the money that comes in through their nonprofit goes to patient care, education, and infrastructure. Those wishing to volunteer or contribute to the efforts can do so through the website www.protesisimbabura.com.
Jason Rovig, CPO, is from the Pacific Northwest and has been on a sabbatical traveling in Latin America for the last year and a half working on projects with O&P organizations, refugee centers, medical groups, and art galleries. His organization, Our Causes; Our Stories, acts as a parent organization for various philanthropic endeavors. Visit www.ourcauses.org.