'GReAT' is a good beginning, but an uphill journey ahead

The first GReAT report is an important global landmark, and India needs to plan its milestones that are goal-directed and results-oriented

Dr Tedros Adhanom Ghebreyesus, Director-General, World Health Organisation and Catherine Russell, Executive Director, UNICEF, jointly released the first Global Report on Assistive Technology (GReAT) on Monday, May 16. A collaborative effort of the WHO and UNICEF, the global impact of the report is expected to be significant. It recognises assistive technology (AT) and enabling environments as a precondition for people in need to realise their human rights and shares evidence-based best practice examples and ten key actionable recommendations on improving access to assistive technology for everyone, everywhere.

What is assistive technology, and why is it important?

Assistive technology (AT) is an umbrella term covering the systems and services related to the delivery of assistive products and services. These include a diverse range of devices and products such as hearing aids, wheelchairs and therapeutic footwear for diabetes. Less commonly known examples are keyboards with large keys or a special mouse to operate a computer for those with limited hand function, software that reads text on the screen in a computer-generated voice for the visually challenged, TTY (text telephone) for the hearing impaired or a device that speaks out loud as they enter text via a keyboard for those with speech impairments.

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Those in need of AT include persons with disabilities, older people, those with non-communicable diseases such as diabetes and stroke and people with mental health conditions including dementia and autism. The most recent global estimate of the need for rehabilitation services estimates that at least one in every three people in the world needs rehabilitation at some point in the course of their illness or injury. Very few countries have national AT policies or programmes; developing a national assistive products list is the starting point. Relatively few can access assistive products, often relying more on charity-based models rather than entitlements. The inclusion of Universal Health Coverage (UHC) in the Sustainable Development Goals (SDG) shall go a long way in addressing the unmet need for assistive products for those with disabilities, the older population and those affected by chronic diseases.

Understanding the AT ecosystem

In the AT innovation cycle, a product needs to complete a long journey to be picked up by the system and be mass-produced to finally reach the users. The AT is relatively new within the larger health system, and AT inequity is far less understood. AT innovation in India is not data or purpose-driven as yet. Valuable funds are spent on research and development of AT prototypes, many of which may not see the light of the day. AT innovators work on the latest complex devices and software, whereas the public sector continues to function on a largely charity-based model; thus, the innovations do not often feed adequately and appropriately into the health system.

The three challenges

India faces an immense challenge in the provision of rehabilitation services in general and ATs in specific. Three key challenges confront us – financing, designing and incorporating ATs into health systems.

What are some of the potential solutions?

Common Goods for Health (CGH) are population-based functions or interventions that require collective financing, either from governments or donors. The recent fast-paced development of the Covid vaccines exemplifies such an approach; the caveat: population-based and preventive services are unlikely to attract the same leverage as disease-based and individual services. For CGH to succeed with respect to ATs, they must be considered a 'common good for heath' to improve human life and promote economic progress and recognise that its provision is at risk of market failure, as these products and services are non-rival and non-exclusionary or they have large social externalities. The WHO estimated, for example, that the return on investment (ROI) of unilateral hearing aids (in low-middle income settings) was US$ 1.62 with a lifetime value of Disability Adjusted Life Years (DALYs) averted of US$3,564. Such estimates for each AT will enable policymakers to understand

The urgent need and long-term benefits.

Design Thinking is an approach that prioritises developing empathy for users, working in collaborative multidisciplinary teams and using "action-oriented rapid prototyping" of solutions. Design Thinking offers the potential for more usable, acceptable and effective AT interventions compared with traditional expert-driven methods. Clinicians and paramedics are not just involved in care delivery processes but are also critical actors with an understanding of the "pain points of the system". Generic designs that are commercially produced are often unable to meet users' needs that are specific, complex and changing over time, limiting the adoption of devices with universal design. Professionals and users are increasingly collaborating to create and provide low-cost and do-it-yourself ATs that have the potential to change the scenario.

Systems Thinking is crucial to the uptake and utilisation of AT for the purpose of achieving UHC. As the WHO emphasises, every intervention "has an effect on the overall system, and the overall system has an effect on every intervention." Systems thinking, specifically in the AT and rehabilitation sector, entails understanding the nature of relationships among the six building blocks (service delivery, health workforce, health information systems, access to essential products, financing, and leadership/governance), the spaces between the blocks and understanding what happens there so that synergies can emerging from the interactions among the blocks. The Systems Thinking approach needs to build several distinct skills.

Drawing upon the WHO's GReAT Summit 2017, systems thinking and non-systems thinking across the 10 Ps have been mandated to promote technological ingenuity and innovation that draws upon design thinking. The 10 Ps are people (users of ATs), policy, products, personnel, provision (as strategic drivers at the systems level) and procurement, place, pace, promotion and partnership (as key situational factors for systems). These elements shall help shape a national programme for assistive technologies that is equitable, resilient and sustainable. The first GReAT report is an important global landmark; India needs to plan its milestone now – that are goal-directed and results-oriented.

(The writer is Chairperson at the Centre of Social Medicine & Community Health, Jawaharlal Nehru University, New Delhi, and a contributor to the GReAT report)