<!-- PERSPECTIVE --> <span style="color: #000000;">How do you provide prosthetics to patients in the developing world? Affordability and empowerment of local providers are the keys to sustainability. We have a long-running experiment in the northern highlands of Ecuador attempting to do just that.</span> <span style="color: #000000;">Patients in Ecuador often leave the hospital after an amputation without knowledge of prosthetics, access to a provider, or even information about how to care for their residual limbs. Unfortunately, many physicians there find that prostheses are just not available for their patients.</span> <span style="color: #000000;">We opened a clinic in Ibarra in 2008 as part of a Rotary International project, financed by the provincial government, that provided free prostheses using donated, high-quality components. Worn-out exoskeletal prostheses were replaced with modern systems, individuals received their first prostheses after waiting many years, and young children took their first steps. But we saw immediately that the project was too dependent on foreigners and began intensive training efforts with physical therapy graduates, who took over operating the project.</span> <span style="color: #000000;">The government funding ended in 2012, and the project quickly went broke. We then instituted a system in which patients paid a sliding fee, depending on the prostheses and their financial situations. We did not know if the strategy would work, but it was so successful that it attracted unwanted interference. As Rotarians ourselves, we were dismayed when local Rotarians took over and decreased employee pay and control, increased costs to patients, and decreased accounting transparency. A downward spiral quickly ensued.</span> <span style="color: #000000;">After eight years, we and all the employees left that group, leaving behind the equipment, funds, and components. We began again, this time setting up a small, private enterprise to fabricate prostheses, working alongside a nongovernmental organization that accepts recycled components and donates them directly to the patients. We have a secure model for the employees who are now owners. They are well connected to our large network of volunteer professionals and donor organizations.</span> <span style="color: #000000;">We have been asked to consult in Ecuador on setting up other prosthetic projects, but the inquiries often focus more on equipment than on the people needed to provide services. Our advice for aspiring projects: The equipment is the easy part. You must connect to a source of components, usually recycled or available at low cost. Most importantly, you must find or develop a strong, local team of providers and be willing to train them, pay them fairly, and provide professional support for them.</span> <span style="color: #000000;">Over the years, professionals from all over the world have volunteered and have given our local prosthetists a well-rounded experience. The learning travels both ways-the caseload is so varied and challenging (most patients walk many miles a day on mountainous terrain) that many volunteers come away with new knowledge. You must adapt to working with the components on hand, and to amputations done without regard for future prosthetic use. And as you adapt to being part of the community, you may be invited to visit your patient's farm on top of a mountain, receive hand-carved gifts, and learn to play the charango.</span> <span style="color: #000000;"><em>Robert Frank, CPO(E), and Kit Frank, OTR, have been volunteering with the rehabilitation community in Ecuador for more than 25 years. They can be reached at <a href="https://protesisimbabura.com/" target="_blank" rel="noopener">protesisimbabura.com.</a></em></span>
