Promoting Universal Health Coverage for Amputees through Social Enterprise and Engineering Innovation

This proposal is focused on extending the international commitment to universal health coverage (UHC) to people suffering limb loss in Low- and Middle-Income Countries. It builds on multi-disciplinary EPSRC- and MRC-funded research establishing the prevalence of limb loss; service-users' experiences of attempting to access and receive services and innovation in the design of 'Fit-For-Purpose' body-powered prostheses. This research has evidenced the need for more comprehensive and structural health systems change focused on the development of an integrated supply-chain system servicing regionally distributed service outlets. At present there is no system to manage and regulate the quality and costs of imports of devices and components from overseas. International donors have played a major role in defining the geography and characteristics of services with an emphasis on internal conflict in Northern Uganda. Since the end of this conflict funding has ceased and underfunded services do not meet needs resulting from significant foreign refugee flows into the West and growing domestic needs arising from Road Traffic Accidents, domestic violence, cancer and diabetes. The Ugandan Ministry of Health (MoH) has proposed the use of Public-Private-Partnerships in health system strengthening. Our proposal will design and test a PPP model as the basis for a more integrated and distributed partnership model to deliver universal health coverage for amputees. National Medical Stores is the sole provider of supplies into public hospitals. With the exception of the National Referral Hospital it is not supplying orthopaedic workshops with essential
supplies and patients who do access these facilities are subject to user fees. Joint Medical Stores (JMS) is an established (not-for-profit) provider of medical supplies to the not-for profit sector. Our proposal focuses on building a PPP platform to support a social enterprise model for supplies management at national level. This will include a more transparent approach to international sourcing combined with efforts to reduce dependency on foreign supplies through local manufacture. We will exploit the potential of an upper limb socket designed by the EPSRC team for local manufacture and task-shifting. We propose a second-level PPP based on a model designed in Fort Portal Regional Referral Hospital to support supply chain management during COVID-19. A recently signed PPP involving an established health partnership with Knowledge for Change, a registered NGO and JMS will design and test a model to promote service-focused supply chain agility at a public hospital located in close proximity to fast-growing refugee camps.

Our long-term aims are to use our innovations in prosthesis design, coupled with fine-resolution modelling of demand, to pilot new, distributed prosthesis service models, characterised through our collaboration with JMS. We propose to pilot a Public private partnership model to help support the more effective integration of foreign aid with one or more of the new service models. Towards the end of the project, we will bring together the key stakeholders to develop a larger scale project which will explore how we can build on the lessons learnt in this study.

Our specific objectives are:

1. Supply Chain Innovation: Co-design and test the contribution that a Public-Private-Partnership approach can make to sustainable supply chain integration for prosthetics componentry and repair services.

2. Demonstrate the role that technological innovation can have on prosthetic services: Test the potential for local manufacture and supply-chain entry of a user-adjustable, locally repairable socket design.

3. ODA Innovation: Generate the evidence-base for a new model for Overseas Development Assistance (ODA) based on principles of partnership, social enterprise and sustainability

In Uganda, as in many other LMICs, prosthetics services have been developed, and supported by international NGOs (e.g. ICRC), in humanitarian responses to conflict. When support is withdrawn, post-conflict, health systems struggle to integrate and maintain such services. Despite the government's commitment to universal health coverage, Ugandan citizens usually have to provide the cost of materials or devices. Local suppliers are scarce and orders from abroad are only made when a user has paid a percentage of the cost. This drives up costs, compromises quality, introduces delays, uncertainties and additional visit. It also makes maintenance a great challenge leading to poor device utilisation. In reality, many amputees do not have access to prosthetic services, although data on access is extremely poor. The Ugandan government adopted the Public Private Partnership (PPP) as a model for health system strengthening, where foreign partners make a significant contribution to public resources. Until now the PPP approach has only been utilised in the not-for-profit hospitals and large research institutions and has not been tested in public services.

Our aim is to determine how engineering and social innovation can improve Uganda's ability to deliver universal health coverage in prosthetic services. We will integrate innovations in prosthesis design, coupled with fine-resolution modelling of demand, to pilot new, distributed prosthesis service models, characterised through our collaboration with Joint Medical Stores via a PPP model. To achieve our objectives, the following work packages are planned: (1) Promoting universal health coverage through health system strengthening and social enterprise; (2) Mapping clinical need, service distribution and quality, and scoping modelling of future services; (3) Evaluating the introduction of appropriate new technology into the Ugandan supply chain; and (4) Engagement and development of a proposal for a follow-on proposal.