The Importance of User Choice for Cost-Effective Wheelchair Provision in Low Income Countries

by Marc Krizack, J.D., Executive Director
Whirlwind Wheelchair International at San Francisco State University

The limited success of free market mechanisms in wheelchair provision in low income countries requires a comprehensive, coordinated, and sustained intervention by governments, charities, and development agencies working in close collaboration with the organized movement of people with disabilities. To be effective, this effort must be designed to stimulate market mechanisms. Up to now, funders have usually subsidized supply, that is, they have purchased wheelchairs that are then given to users. This system must
be turned on its head. Funders must instead subsidize demand, that is, provide funds for wheelchair users to choose for themselves what wheelchairs they want and need.
A healthy market economy tends to correct imbalances in price, quality, and availability of goods and services through competition among producers and feedback from consumer purchasing decisions. The introduction of new products creates new needs and demand and thus provides opportunities for further economic development via a continually evolving array of products and services. A healthy market economy tends toward efficient use of investment resources as each product and service in the web of related products and services develops apace, usually getting neither too far ahead of nor too far behind the demand.

A DISTORTED MARKET
The market economy, however, is skewed when it comes to wheelchairs in low income countries. End users have little money and are most often not the purchasers of the wheelchairs they use. Instead, governments, charities and international development organizations purchase the wheelchairs and give them away. Initial cost is the predominant consideration for these distributors; the wheelchairs provided are rarely built for the
environments in which they will be used. There is little consumer input to make manufacturers and distributors deal with other considerations, such as quality, fitness for use, proper fit, and safety.
Furthermore, a flood of cheap or free imports has the effect of lessening competition by driving out the small, local manufacturers who depend on local governments and charitable organizations, the users, and the users’ families to pay for their chairs.

A STUNTED REHABILITATION INFRASTRUCTURE
The influx of very large numbers of wheelchairs into a region also outpaces the development of secondary facilities, goods, and services, what we will call “the rehabilitation infrastructure” required for users to get the most out of their wheelchairs. The result is that millions of dollars are wasted each year because there are few spare parts to repair the wheelchairs when they break, few repairers trained in wheelchair repair, and few trained personnel to measure and assess users for a proper chair-to-user fit.

THE SOLUTION
The most efficient use of capital resources for wheelchair purchases requires that the number of wheelchairs introduced into any given area not greatly exceed the capacity of the rehabilitation infrastructure to support them. That is, in order for the chairs to be properly fitted, maintained, and repaired, it is better to apportion resources between wheelchairs and these necessary services. A wise intervention will regularly evaluate the capacity of the extant rehabilitation infrastructure, support a commensurate level of wheelchair production,
and build up and extend the capacity of the infrastructure to be able to increase the number of wheelchairs that can be provided effectively.

DEMAND SUBSIDIES
In order for a system of user choice to work, donors would place their money in a managed fund. There should be a variety of wheelchairs, readily accessible consumer information, standards for safety, strength and durability, and trained persons who can advise the users in choosing an appropriate wheelchair. With these elements in place, a user could receive a voucher to purchase the least expensive of the approved wheelchairs that meet the user’s needs. If the user wanted a more expensive chair, the user would have to pay the difference. An adequate pot of money would be attractive to manufacturers who would produce
chairs to meet the users’ requirements. The type and variety of available wheelchairs would grow, along with related services, giving users greater and greater choice and improving a user’s chances to obtain the most appropriate wheelchair for his or her individual needs.

CONCLUSION
Governments, donors and development agencies can learn how best to allocate resources between wheelchairs and wheelchair services/training by participating in a collaborative effort with disabled people’s organizations to provide wheelchair users with the opportunity to choose their own wheelchairs. The resulting feedback will directly benefit wheelchair users and help donors to get the best results in the most cost-effective way.

12th World Congress of the International Society for Prosthetics and Orthotics
Vancouver, Canada, July 29 –August 3, 2007