Methodology for country-level investment case for P&O

Populations in Low and Middle Income Countries (LMICs) typically have a high need for protheses and orthoses which are locally underprovided, despite the right of people to these prosthetic and orthotic (P&O) services under international law (Harkins et al, 2013). This results in a huge loss of welfare and loss of human potential. For example the Global Partnership for Assistive Technology (ATScale) argues that there is a 9 to 1 return on investment from providing assistive technologies, and potential economic gains accruing to 35 million people in excess of USD1.5 trillion from prosthetics specifically, not including health and wider social benefits.

However, although initiatives such as ATScale have made a global case for P&O, action ultimately has to take place at the national level and hence LMIC governments are critical stakeholders. What is needed, therefore, is a framework for building an investment case for P&O at the national level, together an outline national planning framework and, crucially a viable scheme for financing the development and sustainable operation of high quality services in what are extremely resource-poor settings.

A particular difficulty which should be confronted head-on is the poor quality of data in LMIC settings, where civil registration is often limited and vital statistics are patchy or absent; and much healthcare activity takes place in poorly regulated private clinics and hospitals.

Our aim to develop a framework for investment case and national plan development. We propose to focus on the case of Bangladesh. Bangladesh is a lower middle income country in South Asia with a GDP per capita of USD1856 in 2019, according to the World Bank. According to Ali (2014) the cumulative economic costs of disability in Bangladesh is USD1.18 billion. Among other reasons driving demand for P&O in Bangladesh, the country has a very high rate of road traffic accidents with more 15.3 deaths per 100,000 population each year, despite extremely low rates of vehicle ownership (WHO, 2018). Supervisor 1 has published 12 papers on aspects of public health and healthcare financing in Bangladesh and so has familiarity with the country. A former Strathclyde PhD student is now working at the government's internal research institute and thinktank, the Bangladesh Institute of Development Studies and so we have good contacts with relevant in-country institutions.

The CDT students will help create solutions for amputees and people with debilitating conditions such as stroke and diabetes, reducing mortality and enabling them to live more satisfying, productive and fulfilling lives. These solutions, co-created with industry and people living with disabilities, will have direct economic and societal benefits. The principal beneficiaries are industry, P&O service delivery, people who need P&O devices, and society in general.
Industry
The novel methods, devices and processes co-created with users and industry will have a direct economic value to our industry partners (by the creation of IP, new products, and improved industry and academic links). Our CDT graduates will be the natural potential employees of our industry partners and for companies in the wider healthcare technology sector. This will help address the identified critical skills need and shortage leading to improvement in the UK's competitiveness in this rapidly developing and growing global market. The CDT outcomes will help UK businesses spread risk (because new developments are well founded) and more confidently enter new markets with highly skilled employees (CDT graduates).

P&O service delivery
Doctoral engineering graduates with clinical knowledge are needed to improve the deployment of advanced technologies in practice. Our main UK industry partner, Blatchford, stated: "As technology develops it will become easier for the end-user (the patient), but the providers (the clinicians) are going to need to have a higher level of engineering training, ideally to PhD level". The British Association of Prosthetists and Orthotists estimates that no more than ten practising P&O clinicians have a PhD in the UK. Long-term P&O clinical academic leadership will be substantially improved by the CDT supporting a select number of clinically qualified P&O professionals to gain doctorates.

Users
The innovation of devices, use of device and patient monitoring, and innovation approaches in LMIC should not only lead to improved care but also lower healthcare costs. Diabetes UK estimates that the total healthcare expenditure related to foot ulceration and amputation in diabetes was £1billion (2014-15), with 2/3 of this related to foot ulceration. Small innovations could lead to large cost savings if targeted at the right aspects of care (e.g. earlier adoption, and reducing device abandonment).
An ability to work is fundamental to a person's place in society and their sense of purpose and has a significant societal impact in all territories. This is perhaps greatest in LMIC where attitudes towards disability may still be maturing, and appropriate social care infrastructure is not always in place. In these cases, an ability to work is essential for survival.
Improved design approaches will impact on all users regardless of context, since the device solutions will better match local and individual user needs. Addressing issues related to prosthetic/orthotic device abandonment (e.g. cosmesis) and improved adherence should also lead to greater social participation. Improved device solutions will shift focus from what users "cannot do" to what they now "can do", and help progress attitudes towards acceptance of disability.
Societal
The majority of the global P&O users are of working age, and a key economic impact will be keeping users in work. The average age at amputation due to diabetes is just 52 in the USA but much younger in countries with less well-developed health care and trauma services (e.g. 38 in Iran). Diabetes UK reports that 35-50% of people are of working age at diagnosis and that there are around 70,000 foot ulcers in the UK, precursors to amputation. There is a similar concern for stroke survivors around a quarter of whom are of working age and are 2-3 times more likely to be out of work after eight years.