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|The development of orthopaedic appliances and low-cost aids in a least developed country|
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by Andreas Vossberg
Quite often, Western influence has led to the opinion that rehabilitational services are only feasible with the aid of sophisticated appliances. Good appliances, it was believed, ought to be expensive, whereas expensive appliances ought to be good. Indigenous, low cost appliances were generally considered to be of inferior quality.
For this reason, and to do away with these prejudices, this article examines orthopaedic methods as practiced in a Least Developed Country (LLDC) and lays down principles and practical applications that could serve as a foundation for a more appropriate approach in this field.
Various factors to be considered
The adverse circumstances in Least Developed Countries should force politicians, doctors, therapists and technicians to adopt programmes that will not drain the limited financial resources of their countries. Before Western technology and expertise is employed through technical assistance schemes, these schemes should be carefully examined and subjected to the following criteria:
Countries with rudimentary preventive and curative health services should not increase their problems by accepting costly treatment methods of Western origin. Imported products either burden the local budget or must be dependent on foreign aid. Such products add to the burden of rapidly increasing labour costs, profits, commissions, and transport expenditure. Only those aids which lead to indigenization of orthopaedic technical services will break the dependence on hard-currency investments.
The majority of disabled persons who require technical remedies fall into the category of destitutes. These people cannot be burdened with costly treatments and/or medical appliances, since it is unlikely that any governmental agency will take up the burden of their behalf.
Appliances of industrial origin are generally designed for the specific living conditions and high standards of civilized urban societies. These appliances do not necessarily meet the needs of the people in Asia, Africa, or Latin America, with their own distinct conditions and living standards.
In the tropical countries of the southern hemisphere we are confronted with diseases and their aftermath which necessitate the development of orthopaedic appliances particularly suited to the socio-medical environment and to the high incidence of particular disabilities.
Up to 90 per cent of the patients live in rural areas. Hence, the technology must be adapted to poor infrastructures and the availability of local materials as well as to the manual technical ability of the people.
Sophisticated, costly remedies cannot contribute effectively to improving the conditions of the widely neglected, untreated, disabled population.
Guideline for technical counselling
Technical counselling requires, in the first place, clear determination to serve the interests of the host country, followed by a high level of flexibility and the ability to adapt to local conditions. Every situation has its own particular advantages and disadvantages, and a rigid attitude towards the implementation of programmes is doomed to failure.
One of the most common errors in the past has been that industrialized nations tried to introduce their own standards without taking the social environment of the target group into account. Therefore, technology should never be viewed in isolation but only in the context of a global approach covering all socioeconomic and cultural aspects.
This survey shows the material supply for orthopaedic appliances and low cost aids in Nepal.
Drawing: Andreas Vossberg
With this basic fact in mind it seems to be appropriate to design a scheme with the following principles in mind:
· give ample time to study and understand the social environment
· define the program's priority areas
· investigate traditional methods and materials
· on the basis of your findings develop indigenous appliances
· test the same in conditions which are typical of the country
· explain your appliances by means of illustrations and descriptions
· propagate the philosophy of an appropriate orthopaedic technology.
This approach could lead to the replacement of an inappropriate, expensive and highly sophisticated technology by a system superior in terms of being well-balanced and cost-beneficial.
Scope for development of indigenous orthopaedic appliances and low cost aids
This section deals with practical matters in relation to applied technology. Professionals are advised when planning their programmes to adopt the principles and methods suggested and to adapt their programmes to suit local resources and limitations.
In the first place, the availability of local material will determine the possibilities for production of orthopaedic appliances. Even if the bulk of materials required has to be imported from neighbouring countries, the production costs can still be kept at a comparatively low level. At present, a great number of least developed countries meet their requirements for basic materials, e.g., prefabricated components, ready made orthopaedic appliances, and rehabilitational equipment by special order from industralized countries.
A recent in-depth study, carried out in Nepal, has disproved the commonly-held opinion that the supposed non-availability of suitable materials on the local market justifies importing costly >>high tech<< items. The investigation gives substantial evidence that local resources do in fact exist.
The diagram indicates clearly that an orthopaedic technical service can to a great extent rely on indigenous raw material (Category A) as well as readily available goods imported from neighboring countries
(Category B). Articles which fall into the third category (C) can be imported by special order, except those which are obtainable through specialized Orthopaedic Suppliers.
There is a lot of misunderstanding and contradiction when it comes to interpreting correctly the terms "appropriate technology" and "technology transfer".
While the former term is tainted with the idea of being poor as regards quality and effectiveness, the latter suggests to many something modern, sophisticated and exorbitantly expensive.
However, taking a more balanced view, it is possible to see that the two concepts do not have to stand in sharp contrast to each other. Both of them have enormous potential, provided they are carefully adapted to the local situation. On the one hand, the use of modern technology may demand considerable modification, but on the other, more tradition-oriented technology may benefit from fresh technological inputs.
With this willingness to adapt, the two concepts can easily complement each other. Least developed countries can strive to exploit their own resources while at the same time absorbing contemporary scientific ideas.
In considering the possibilities in LLDC's, we should be aware that in most countries the local infrastructure may already be sufficient to provide a basic technical service, which can meet the most essential needs. In developing a project of this nature, the following guidelines should be applied:
· first explore indigenous methods
· keep production techniques as simple as possible
· give preference to small production units
· keep capital investment low.
Bear in mind particularly that technology and construction based on local materials and traditional methods should be maintainable with relatively little expense and without requiring specific technical and organizational expertise.
A standardized system
The preparation of standardized appliances will avoid frequent >>bottleneck situations<< by accelerating the service to each individual patient. Furthermore, the system will contribute effectively to avoiding the expense of using skilled paramedical manpower in routine work.
The evolution of a standardized system can only be accomplished by experienced professionals who are able to gather extensive data. Their morphological and pathomechanical observations in connection with physically disabled patients are essential at every stage of designing an orthopaedic appliance.
An independent research project should observe the following principles:
· develop a uniform system for collecting data and taking patients'measurements
· coordinate designs to suit different anatomical dimensions
· follow basic biomechanical principles
· refine the appliances by constant checking and evaluation
· classify the range of interchangeable modules by a standardized numbering system
· familiarize doctors, therapists, orthopaedic technicians, and other paramedicals with the method of selecting and assembling modules and especially of adapting standardized appliances to the individual patient.
The use of standardized orthopaedic appliances will make the fitting procedure easier and quicker, thus relieving busy orthopaedic technicians and paramedicals from heavy work loads. This in turn should have a positive effect in reducing treatment sessions or hospitalization.
While foreign companies have made advances in marketing their components in remote, exotic places, too little attention has been given to exploring the local infrastructures and tapping local resources.
While overseas technical assistance has created model institutions run by a cadre of highly skilled technicians, insufficient attention has been given to the potential of readily-available, semi-skilled manpower able to manufacture low-cost appliances on a larger scale.