We welcome you to this first edition of the Disability and Healthcare Technology newsletter, which will be issued twice yearly under the commission of the Department for International Development (DFID). The newsletter is edited and published jointly by GIC Limited and Healthlink Worldwide, the managers of the Knowledge and Research Programme on Disability and Healthcare Technology (KaR Programme). The objective of the newsletter is to tell readers about disability and healthcare technology activities under the KaR Programme as well as interesting relevant projects funded elsewhere. Other newsletters are being issued to cover KaR Programmes on Water and Sanitation, Urbanisation, Transport, Energy Efficiency and Geoscience.

This newsletter is aimed at organisations and individuals who are active in the fields of disability and healthcare technologies. It aims to provide its readers with an update on the progress made within these fields by the projects sponsored both by DFID and by other aid agencies. Some initial results are already available in this edition but most projects are still at an early stage. The results of these projects will be made available in later editions. We believe you will find this newsletter informative. Please write to us with your ideas and comments for future editions.

In September 2000, DFID launched the £1.2 million KaR Programme on Disability and Healthcare Technology. The programme is financed jointly by DFID's Infrastructure and Urban Development Unit, Social Development Unit and Health and Population Unit, but differs from other KaR Programmes in that it is not managed by DFID. Instead, the programme is run by a unique partnership between a management consulting firm, GIC Limited, and a non-governmental organisation, Healthlink Worldwide. Decisions on project eligibility are made by a Programme Advisory Group, which comprises representatives from DFID and the World Health Organization (WHO), specialists in disability and healthcare technology, and managers from Healthlink Worldwide and GIC.

The programme aims to support the development and application of healthcare technologies and infrastructure and to minimise the detrimental effects of disability on the lives of many poor people in developing countries. In particular, it finances projects that either:

• develop a new technology

• adopt a newly developed technology

• contribute to the wider use of a successful technology.

It defines technology as including processes and management practices, organisational and supportive systems, and the knowledge associated with these. In order to be selected, projects must address either "hard" aspects of technology (mainly equipment), or "softer" issues: these may cover, for example, the question of how policies and systems can be developed to manage such "hard" technologies, or to improve the delivery of health services and equipment to the poor and the disabled.

To ensure that the new initiatives financed by the programme are effective in improving the lives and health of poor and disabled people in developing countries, the programme further stresses that the technology should be widely applicable in a range of developing countries at an affordable cost. It must be possible to scale-up technology that has been successful on a small scale to a level big enough for it to make a difference. It must provide sustainable results and be replicable in different environments.

Additionally, if the widespread adoption of technologies is to be achieved, it is essential that information about the lessons learnt should be widely disseminated and that the knowledge associated with its use should be widely shared. For this reason, organisations receiving funding under the programme undertake to ensure results are disseminated as widely as possible. A summary of the main research results will be made available on the KaR website: http://www.kar-dht.org

An initial group of six research projects was approved for funding under the fast-track procedure in December 2000. This was followed by a competition, which ended in May this year. A further 12 projects were selected, reflecting a good balance between small and large projects, disability and healthcare technology and the three categories identified above, as well as covering a broad geographical area. Their implementation phase will start in July 2001. Most projects will receive 100 per cent of the funding requested. It is possible that a second competition will be held.

For further information please email: kar@giclimited.com

Have you ever tried obtaining support for a project proposal that does not fit neatly into the scope of an existing donor research programme? It is not an easy task. This problem was one of the key drivers behind DFID's KaR Programme on Disability and Healthcare Technology.

DFID supports a range of KaR Programmes, which complement and feed into its mainstream development work. Traditionally, these programmes have been developed and managed by individual departments within DFID. This new initiative is one of the first to be developed as a genuinely inter-disciplinary programme and was designed specifically to bridge a gap between the existing KaR Programmes of three separate departments:

• Infrastructure and Urban Development

• Health and Population

• Social Development.

It has been developed in close co-operation with WHO.

Previously project proposals that focused on disability and healthcare technology could not easily be supported under any of the other DFID KaR Programmes. They often fell short of meeting the financing criteria of any one programme and were hence left unfunded. The creation of the new programme addresses this problem by concentrating on strengthening projects that either support the development and application of healthcare technologies and infrastructure, or minimise the detrimental effects that disability has on the lives of many poor people in developing countries. Projects are prioritised on the basis of those most likely to have a real impact on the lives of the poor and disabled in developing countries.

In preparing this programme, DFID conducted an extensive consultation process to assess the demand and to ensure the best approach was adopted in addressing the issues. This consultation involved over 60 organisations from the UK, developing countries and multilateral organisations, and identified a clear role for DFID to play. We are confident that the projects supported will make a useful contribution to international development targets, especially those dealing with improving health for poor people and human rights for all.

But, as ever with a new programme of this sort, the real value will not be known until we start to see evidence that individual projects are actually having an impact on the lives of poor and disabled people in developing countries. This newsletter provides just a taster of some of the projects that are being supported. I will follow future editions with interest, to see how quickly this newborn programme, so long in its gestation, can come of age.

The performance of healthcare delivery systems is, to a large extent, determined by the state of technology and physical infrastructure. It is vital to ensure that these are available in an appropriate mix and are properly managed throughout their life-cycle in order to meet the health needs and expectations of the population, and to use scarce resources effectively. When they are not, it is usually the poor that suffer most.

The pace of infrastructure expansion and technology proliferation over the last few decades has, however, far exceeded the capacity of many developing and transitional countries to introduce required changes into technology support systems, thus causing serious imbalances. When planning facilities and acquiring equipment, health authorities often fail to differentiate between needs and wants, to appreciate recurrent cost implications, and are unable to provide adequate institutional basis, management expertise and technical skills for their effective use. Poorly planned investment, wrong technology choices and inappropriate management of acquired technology result in half of the inventory lying idle, leading to an inadmissibly high cost of loss in both health outcomes and monetary terms. One most urgently needed reform is to strengthen technology management capabilities within health systems to achieve equitable and sustainable access to quality health services, particularly to poor and vulnerable populations.

This problem is widely recognised, and numerous programmes are under way to improve the planning, acquisition and utilisation of health infrastructure and technology. The World Health Organization has been leading these developments since the 1987 launch of the WHO Global Action Plan on Management, Maintenance and Repair of Health Care Equipment. The plan has been instrumental in raising awareness among decision-makers in countries and in the international community, identifying problems and possible solutions, providing important guidance on best practices supported by relevant management tools, and building managerial and technical capacities at all levels. It has evolved into a comprehensive programme with a wide spectrum of advocacy, normative and technical support activities, and has promoted the creation of a worldwide network of international agencies and national institutions. These share a common vision and have accumulated a wealth of collective knowledge on how to plan and implement effective healthcare technology policies and strategies.

However, the global impact of these initiatives remains limited due to the magnitude of the problem. More research and dissemination of existing information are needed if the overall quality of care to poor and disabled people in developing and transitional countries is to be improved significantly. In particular, there is a need to adapt successful solutions to specific country circumstances, to develop more practical decision-support tools that strengthen country capacities, and to produce more widespread evidence as to which approaches work and which do not.

The new DFID-supported KaR Programme on Disability and Healthcare Technology presents a unique opportunity to contribute significantly to the public fund of knowledge in this area. WHO has been closely involved with this initiative at all stages and trusts that projects funded under the programme will, by providing answers to some of these long-standing questions, help to address the problems that hinder better healthcare provision in developing and transitional countries, where the majority of the world's poorest and most vulnerable people live.

Professor Andrei Issakov

A KaR-funded project to make existing disability knowledge and information more widely available.

Disabled people are often among the poorest and most marginalised members of any community, and there is a real need for practical initiatives that improve disabled people's lives. But it is also important to document and share information on the many innovative activities that are making a difference. This will help ensure that projects are aware of related activities in other parts of the world, that national and international policies are developed with reference to community experiences, and that the international response to disability is well co-ordinated and more effective.

For many years, Healthlink Worldwide and its partners, for example the Centre for International Child Health (CICH), have been seeking to address this need for disability-focused information management by collecting and cataloguing relevant material on disability and developing electronic databases of these collections. The International Good Practice on Disability Project, managed by Healthlink Worldwide and financed by the KaR Programme, has given added impetus to this work.

The physical collections of Healthlink Worldwide and CICH have been merged to form the SOURCE International Information Support Centre, which is housed in the Library of the Institute of Child Health in London, UK. The KaR-funded project has, for example, enabled SOURCE to identify, index and catalogue a lot more material and the collection now consists of about 3,000 items. This includes published material, such as books, articles from periodicals and journals, and monographs, as well as unpublished or 'grey' literature, such as evaluation reports. SOURCE emphasises documenting and sharing experiences from developing countries as well as important international research. For instance, as part of the KaR-funded project, SOURCE has indexed and catalogued a report of the proceedings of the second national seminar of the Botswana Council for the Disabled. The physical collection can be accessed free at the SOURCE Information Support Centre, which will be officially launched at the end of October 2001.

The physical collection is complemented by many disability-related electronic resources. These have also been significantly strengthened by the KaR-funded project. For instance, an electronic database of materials available in the SOURCE collection will be searchable free from the SOURCE website. This bibliographic database will also be available on CD-ROM. The KaR-funded project is also supporting the development of SOURCE's electronic database of contacts for individuals and organisations working in disability worldwide.

An important part of the work supported by the KaR-funded project is signposting visitors and users to other sources of disability-related material. This includes useful websites and printed and electronic databases, such as the Japan-based Disabilities Information Resources - a free source of online documentation for Asia and the Pacific.

As part of the KaR-funded project, highlights of materials available in the physical collection, as well as important electronic resources, will be made available as a printed directory. The directory, together with the databases, will also be used to guide the KaR Programme Advisory Group to assess the needs for future disability-related research.

Established in 1977, Healthlink Worldwide works in partnership with organisations in developing countries to improve the health and well-being of poor and vulnerable communities by strengthening the provision, use and impact of information.

A KaR-funded pilot project in The Gambia aims to support a culture of maintenance for medical equipment in the developing world.

In its report Primary Healthcare Concepts and Challenges in a Changing World (1997) WHO estimates that `less than half of the medical equipment in developing countries is useable'. It concludes that there is a major and urgent need to address equipment maintenance in order to improve the quality and provision of healthcare. Such findings come as no surprise to anyone who regularly visits health facilities in the developing world, but how this problem might be tackled has been exercising us at ECHO for some time.

Two years ago ECHO began talking to DFID about an outline concept for a project focusing on the needs of equipment maintenance staff, to help tackle some of the problems that ECHO commonly came across when talking to such people in the field. The opportunity to put these ideas into practice came in the form of fast-track KaR funding for a pilot project at the beginning of 2001.

The project is very simple, combining a short element of field-based training with longer-term support in areas such as tools, spare parts, consulting and networking. While the training can help to boost the skills and confidence of technical maintenance staff (as well as immediately repairing a selection of equipment for the host facility), ECHO believes the second part of the project will be most crucial to sustainability: improved morale and the right tools for the job are essential if health facilities are to retain higher calibre staff in technical maintenance roles. In turn, health facilities with a successful maintenance programme will reduce their need for new equipment and can better use their resources for patient benefit.

For our pilot project we chose The Gambia, not only because of the strong links that ECHO enjoys with the Department of State for Health and the Medical Research Council there, but also because the small size and logistics of the country made it relatively easy to include staff from a wide range of facilities in the one pilot project. The three-week training component was carried out by ECHO's Senior Biomedical Engineer, Andrew McDowell. There were 34 participants, from 11 hospitals and health centres throughout The Gambia.

As one objective was to promote awareness about the importance of the maintenance function, the first week of the course was largely based around discussion of the principles and philosophy of maintenance, along with the benefits of an effective management culture. Participants were able to air their views, frustrations and ideas, and in this way also validate (or not) ECHO's own proposals for the sort of continued assistance it should provide in the future. The next two weeks concentrated on hands-on maintenance work, servicing and maintaining equipment at the Royal Victoria and Bansang Hospitals. Participants were encouraged to work together on a wide range of medical equipment, on tasks that were challenging, but also appropriate to their level of skills.

The level of education and experience of candidates varied enormously, with some having done long training courses overseas, while around 25 per cent needed considerable help even to complete the pre-course questionnaires. Despite the diversity of backgrounds and skills a strong bond quickly developed between participants. All were keen to join in the discussions and ask questions, and all united in their enthusiasm to improve their skills and work together on common problems. Issues such as lack of resources, spares and basic tools cropped up time and time again, along with the isolation and low status often felt by those doing maintenance work.

Bringing course participants together was a valuable outcome in itself, but it was the level of enthusiasm and participation that each person brought to the exercise - teaching as well as learning, and also helping us learn how to help them in the future, which fostered real hope for lasting benefits.

With the pilot training now completed we are continuing to provide long-term assistance to participants. Andrew McDowell will return to The Gambia in August to provide further support, as well as reporting back on how this exercise may have affected facilities and maintenance staff. One more evaluation will take place in November, after which reports and findings from the project will be made available through KaR.

Established in 1966, ECHO International Health Services is a UK charity specialising in the supply of quality assured pharmaceuticals and medical equipment to governments and the humanitarian sector around the world. Over the years ECHO has developed expertise in training, technical and advisory support to health facilities.

If you are wearing glasses to read this article, take them off and consider how you would manage without them. According to WHO one billion people worldwide need vision correction but do not have access to it. Almost all of them live in the developing world, where eye health infrastructures are often rudimentary. Statistics show the global divide in eye health, including access to glasses: in Europe the number of eye health professionals per head of population is about 1:8,000, compared to 1:100,000 in south Asia and 1:1 million in sub-Saharan Africa.

But what about the people and communities behind these statistics? The millions of people who are unable to carry on working because they can no longer see clearly? How do men, women and children become and remain literate if they cannot see the text in books or on chalkboards?

How do people prepare food if they cannot tell the difference between a grain of rice and a stone? How do people avoid being cheated in the market if they cannot see the money clearly? And when so many drivers cannot see clearly, is it surprising that by 2020 road accidents are forecast to rise to second place in terms of life years lost in the developing world?

While much work continues to be done into the global impact of blindness, there is virtually no data on what it means to have one-fifth of the world's population living with uncorrected poor vision. This is the background to ground-breaking international research initiated by Adaptive Eyecare (AEL) and funded by the KaR Programme.

This first phase of research into the economic and social impact of un-corrected vision was designed for AEL by the Economists Advisory Group Limited and is being managed by GIC Limited in partnership with the Lions Aravind Institute for Community Ophthalmology (LAICO) in India and the Ghana Institute for Linguistics, Literacy and Bible Translation (GILLBT) in Tamale, Ghana.

The Indian research is studying the impact of poor sight on worker productivity and employment in the textile industry, while the Ghanaian study is investigating the widely-held belief amongst adult literacy professionals that uncorrected poor vision is a primary cause of learners dropping out of classes and failing to become literate.

Both studies are due for completion by July 2001, after which the findings will be made available. AEL and its many international collaborators hope this will lead to more studies of what has, up to now, been an almost entirely ignored economic and social burden for developing countries.

Adaptive Eyecare are pioneers in wearer-adjusted corrective eyewear. AEL's award-winning adaptive spectacles are fitted with revolutionary lenses filled with silicon oil. These can be focused by the wearer to suit their personal requirements. The technology is increasingly seen as a simple and cost effective way of delivering affordable sight correction to developing world populations.

It is estimated that only two per cent of the people in Africa who need a wheelchair actually have one and that locally-produced wheelchairs meet just one per cent of the need. Motivation's Wheel-chairs for Africa programme, which recently received funding through KaR's fast-track procedure, is addressing both these issues by equipping people from Africa with the skills they need to start building up Africa's own capacity to make wheelchairs.

The project was established in recognition of the enormous scale of the problem, with Motivation having received over 70 requests for help with wheelchair provision from 25 African countries.

Since December 1999, Motivation has been working in Moshi, Tanzania, with the Tanzania Training Centre for Orthopaedic Technologists (TATCOT). There Motivation has developed the world's first-ever wheelchair technologist's training course. Having first written a detailed curriculum and then trained the trainers, the course began last October and will last a year. It gives up to eight students a year the chance to learn everything they need to know about how to run an efficient, self-financing workshop on wheelchair production. The first year's students come from Tanzania, Uganda and Zimbabwe and are all disabled themselves.

It is essential that the students come to understand all the principles of wheelchair design so that they can adapt what they have learned to suit local conditions and availability of materials in their own countries.

As well as technology and design elements, the course also places considerable emphasis on workshop management, sustainability and therapy issues.

Training will not finish with the completion of the course. It will include follow-up with the students when they are back in their own workshops, to support them as they put what they have learnt into practice. Motivation therapists will also work closely with recent graduates to develop in-country wheelchair distribution systems, teaching them how to identify the most suitable wheelchair for an individual disabled person. Also, mobility training for new wheelchair users will be introduced so that people learn to make the best possible use of their wheelchair.

Motivation is aware that even the low-cost wheelchairs the graduates will be making may still be out of reach for many Africans. They will therefore work with local organisations to set up schemes to enable the poorest disabled people to obtain wheelchairs. This will include financing schemes so that people can buy their wheelchairs over a period of time, and "wheelchair funds" to help the poorest disabled people to meet the cost.

Augusti Mboyi, a trainer on the course, summed up the sense of excitement for all involved with the Wheelchairs for Africa programme. `We have gained a lot of knowledge over this year, but it is just the beginning.'

Motivation is an international disability charity based in Bristol. Since its first project in 1991, it has successfully established 15 self-sustaining projects in 14 countries.

For more information about Motivation or the project, please contact Lucy Day on day@motivation.org.uk

No water in the operating theatre; no fuel for the emergency electricity generator; leaking medical gas lines wasting oxygen; no spare parts; no service manual to repair the anaesthesia machine…

Every healthcare technology engineer who has worked or is working in developing countries is familiar with situations similar to these. Weak administration of healthcare equipment, due to a lack of local technical and managerial know-how, combined with often ill-targeted aid, ends up in wasted resources with little or no benefit to patients.

The Global Knowledge Network Project, conducted by GIC Limited with extensive coordination and cooperation from active players in the field of healthcare technology, has set out to address this problem. It aims to compile and update an indexed knowledge database of individuals, institutions, publications and web-sites, relevant to the healthcare sector. Once completed, this database will include organisations active in improving healthcare technology management, useful publications and documentation, software for functions such as planned preventive maintenance and assets control, and contacts for manufacturers and suppliers.

Building this database has turned out to be easier said than done. The three teams producing the database specialists from the healthcare technology and biomedical engineering sector, universities and WHO noted that many organisations which could be expected to have a web entry have none or at most an inadequate one.

Parallel to this database, the project is surveying healthcare delivery institutions in selected developing countries, in order to identify priority areas for information and training needs.

Responses so far show that the greatest problems facing biomedical technicians, clinicians and managers are not technical ones related to keeping the equipment working but management and financial constraints.

For example, equipment that is not fit for purpose is being ordered or proper calculations are not being made of the financial affordability of the future operations and maintenance.

We foresee two direct benefits coming out of this project:

• a ready source of useful contacts on the database for technicians and managers needing "how to" and "where from" information. For example, how to calculate the recurrent maintenance cost of a particular x-ray system, and which agent stocks spare parts.

• a clearer picture of the principal areas to be addressed in future to strengthen policy and management aspects of healthcare technology.

The database is being converted into a format suitable for Internet publication, with suitable integral search facilities, and should be operational shortly. It will eventually be accessible via the KaR website or in hardcopy. The survey is very small scale but focused. Together they will provide the start of a rational basis for future research priorities for this KaR programme.

GIC Limited is an international management consultancy firm specialising in project management, training and consultancy in healthcare, trade and international funding institutions.

The following projects were approved in January under the fast-track procedure and have been in implementation since February 2001.

Aims to design and develop a Wheelchair Technologist Certificate course to train up to eight people a year in the production of specifically designed wheelchairs appropriate for use in developing countries.

Seeks to develop, deploy and evaluate a new data collecting and management system for Lilongwe Hospital in Malawi, and learn lessons for replication elsewhere. The system consists of clinical workstations that use a touch screen interface and are connected to a central server through wireless networks.

Aims to provide local pilot training to hospital staff on technical maintenance of equipment and assess the benefits of such training. The lessons of this project will serve to help set up a broader training programme for hospitals in developing countries.

Aims to generate data on the economic consequences of uncorrected vision. The results will be used to advocate for funding of further research to produce evidence to convince policy makers of the need to include vision correction in their agendas.

Aims to improve access to, and availability of, information related to healthcare technology (including management practices) for healthcare delivery institutions and health professionals in developing countries. The two research assignments are: assembly and maintenance of a knowledge database; a survey of healthcare delivery institutions to identify where information and training needs are not being met.

Seeks to document learning from published and unpublished disability literature and make it available to those working on disability in developing countries, to help them incorporate this learning into their own work. The findings will be made available in a printed directory, a CD-ROM and two electronic databases.

The following projects were approved by the KaR Programme Advisory Group in May 2001.

Aims to design a mass-production system to prefabricate low-cost thermo-plastic knee-ankle-foot orthoses for rapid production, easier assembly and fitting in large quantities, as an alternative to mainstream metal calipers.

Aims to establish an international production centre for high-volume manufacture of low-cost wheelchairs, appropriately designed for use in developing countries.

Seeks to increase access to communication for blind people through the improvement of a prototype low-cost mechanical Braille writer in order to make it suitable for local manufacture and repair for staff with limited skills and resources.

Aims to empower parents, families and community members with rehabilitation techniques, to enable them to better manage and reduce the negative impact of disability on affected children as well as guide them towards seeking appropriate help.

Seeks to validate a new instrument that measures children's communication disabilities, and use this tool to measure the impact of community-based interventions to address these disabilities.

Aims to improve the technology for identifying disabilities among children to ensure these are detected as early as possible so appropriate follow-up interventions can be taken.

Aims to improve solid waste management within the Nepalese health services and, by involving public sector representatives, contribute towards the development of a defined policy for this sector.

Development of generic practical Health Care Technology Management Procedure Guides for health service staff in developing countries to help them in their daily management of equipment. In collaboration with WHO.

Aims to increase the efficiency, reach and impact of health information dissemination. The project will produce and distribute free CD-ROMs containing training materials and information to health workers in the South.

Aims to determine whether the established technology used for controlling tsetse and tick-borne diseases with insecticide-treated cattle could also be used to control malaria in rural areas where livestock plays an important role in keeping malaria-transmitting mosquitoes alive.

Aims to establish a virtual International Healthcare Technology Management Centre to act as a support, networking and reference resource for healthcare practitioners. To facilitate further dissemination of information, the website will link relevant international and regional websites and will include newsletters, best practice guidelines, policy frameworks and networking tools.

The website for this KaR programme is at www.kar-dht.org

The main EnG-KaR website, which gives an overview of the programme and links to the other sites, is at www.dfid-engkar.org.uk