Guidelines on the provision of

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in less resourced settings

Guidelines on the provision of

BVcjVaL]ZZaX]V^gh
in less resourced settings

WHO Library Cataloguing-in-Publication Data
Guidelines on the provision of manual wheelchairs in less-resourced settings.
1.Wheelchairs - economics. 2.Wheelchairs - supply and distribution. 3.Wheelchairs - standards. 4.Disabled persons - rehabilitation. 5.Developing
countries. I.World Health Organization.
ISBN 978 92 4 154748 2(NLM classiﬁcation: WB 320)

© World Health Organization 2008
All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia,
1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce
or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address(fax: +41 22 791 4806; e-mail: permissions@who.int).
The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the partof the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitationof its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
The mention of speciﬁc companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World HealthOrganization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products
are distinguished by initial capital letters.
All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, thepublished material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of
the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.

Contributors:
Editorial committee
Editors
Authors
Peer reviewers

Illustrator
Testimonial authors
Financial support
Partner organizations

Geoff Bardsley, Marc Krizack, Abdullah Munish, Kim Reisinger, Sarah Sheldon
Johan Borg and Chapal Khasnabis
William Armstrong, Johan Borg, Marc Krizack, Alida Lindsley, Kylie Mines, Jon Pearlman, Kim Reisinger,
Sarah Sheldon
Jocelyn Campbell, Stefan Constantinescu, Fiona Gall, K N Gopinath, Sepp Heim, Ralf Hotchkiss, R Lee Kirby, Anna
Lindström, Matt McCambridge, Shona McDonald, Ray Mines, Alice Nganwa, Jamie Noon, Tone Oderud, Alana Ofﬁcer,
Valeria Rodriguez, Osten Safvelin, Elsje Schefﬂer, Harold Shangali, Edd Shaw, Gertrud Stehr Hott, Claude Tardif, Isabelle
Urseau, David Werner
Jen McKinlay
Elly Bernard, Anca Beudean, Tun Channareth, Fiona Gall, Matt McCambridge, Shona McDonald, Laura Morales, Keo
SovannUS Agency for International Development
Centre for International Rehabilitation, Disabled Peoples’ International, International Society for Prosthetics and Orthotics,
The Motivation Charitable Trust (Motivation), Whirlwind Wheelchair International (Whirlwind) at San Francisco State
University

Design and layout was done by L’IV Com Sàrl.

I67A:D;8DCI:CIH

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13&#>cigdYjXi^dc

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1.1 Appropriate wheelchairs
1.2 Users of wheelchairs
1.3 Need for wheelchairs
1.4 Rights to wheelchairs
1.5 Benefits of wheelchairs
1.6 Challenges for users
1.7 Wheelchair provision
1.8 Types of wheelchair
1.9 Stakeholders and their roles
1.9.1 Policy planners and implementers
1.9.2 Manufacturers and suppliers
1.9.3 Wheelchair services
1.9.4 Professional groups
1.9.5 International nongovernmental organizations
1.9.6 Disabled people’s organizations
1.9.7 Users, families and caregivers'#9Zh^\cVcYegdYjXi^dc
2.1 Introduction
2.2 Wheelchair design
2.2.1 General considerations in wheelchair design
2.2.2 Introducing wheelchair design
2.2.3 The design process
2.3 Wheelchair production and supply

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4 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

2.4 Functional performance
2.4.1 Wheelchair stability
2.4.2 Manoeuvrability
2.4.3 Pushing efficiency
2.4.4 Other functional performance characteristics
2.4.5 Evaluating functional performance
2.5 Seating and postural support elements
2.5.1 Seat bases
2.5.2 Cushions
2.5.3 Backrests
2.5.4 Footrests
2.5.5 Armrests
2.5.6 Rear wheels
2.5.7 Evaluating seating and postural support elements
2.6 Strength, durability and safety
2.6.1 Requirements
2.6.2 Evaluating strength, durability and safety
2.7 User trials and follow-up(#HZgk^XZYZa^kZgn
3.1 Introduction
3.2 Wheelchair service delivery
3.2.1 Steps in service delivery
3.2.2 Understanding individual user needs
3.3 Good practice in wheelchair service delivery
3.3.1 Overall service
3.3.2 Referrals and appointments
3.3.3 Assessment
3.3.4 Prescription
3.3.5 Funding and ordering
3.3.6 Product preparation
3.3.7 Fitting
3.3.8 Training of users, families and caregivers
3.3.9 Follow-up, maintenance and repair
3.4 Personnel in wheelchair service delivery
3.4.1 Manufacturers or suppliers
3.4.2 Referral networks
3.4.3 Service personnel
3.5 Monitoring and evaluation
3.5.1 The need to measure performance
3.5.2 Monitoring
3.5.3 Evaluation

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TA B L E O F C O N T E N T S)#IgV^c^c\
4.1 Introduction
4.2 Training requirements
4.2.1 Referral networks
4.2.2 Role of wheelchair service providers
4.2.3 Trainers
4.3 Course modules and contents
4.3.1 Course modules
4.3.2 Course contents*#Eda^XnVcYeaVcc^c\
5.1 Introduction
5.2 Policy
5.2.1 Developing a policy
5.2.2 International policies
5.2.3 Specific wheelchair provision issues
5.3 Planning
5.4 Funding strategies
5.4.1 Costing
5.4.2 Sources of funding
5.5 Links with other sectors
5.5.1 Health services and community outreach campaigns
5.5.2 Education
5.5.3 Livelihood
5.5.4 Social
5.5.5 Infrastructure
5.6 Inclusion and participation

6ccZm6
Training resources
Other resources

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EG:;68:
The wheelchair is one of the most commonly used assistive devices for enhancing personal
mobility, which is a precondition for enjoying human rights and living in dignity and assists people
with disabilities to become more productive members of their communities. For many people, anappropriate, well-designed and well-fitted wheelchair can be the first step towards inclusion andparticipation in society.
The United Nations Standard Rules on the Equalization of Opportunities for Persons with Disabilities,
the Convention on the Rights of Persons with Disabilities and World Health Assembly resolution
WHA58.23 all point to the importance of wheelchairs and other assistive devices for the developingworld, where few of those who need wheelchairs have them, insufficient production facilities exist,
and all too often wheelchairs are donated without the necessary related services.
When the need is not met, people with disabilities are isolated and do not have access to the same
opportunities as others within their own communities. Providing wheelchairs that are fit for the
purpose not only enhances mobility but begins a process of opening up a world of education, workand social life. The development of national policies and increased training opportunities in thedesign, production and supply of wheelchairs are essential next steps.
In the light of the realities of the developing world and the immediate need to develop functioning
systems of wheelchair provision in less-resourced parts of the world, the World Health Organization(WHO), the US Agency for International Development, the International Society for Prosthetics
and Orthotics and Disabled Peoples’ International, in partnership with the Centre for International
Rehabilitation, the Motivation Charitable Trust and Whirlwind Wheelchair International, havedeveloped this document to assist WHO Member States to create and develop a local wheelchair
provision system and thereby implement Articles 4, 20 and 26 of the Convention on the Rights of
Persons with Disabilities. We extend our thanks to the US Agency for International Development’s
Patrick Leahy War Victims Fund for its support in producing these guidelines and assisting in theirimplementation.

Etienne Krug

Lloyd Feinberg

World Health Organization

US Agency forInternational Development

Dan Blocka

Venus Ilagan

International Society for Disabled Peoples’ International
Prosthetics and Orthotics

:M:8JI>K:HJBB6GN
These guidelines seek to promote personal mobility and enhance the quality of life of wheelchairusers by assisting Member States in developing a system of wheelchair provision to support theimplementation of the Convention on the Rights of Persons with Disabilities (and specifically Articles
4, 20 and 26) and World Health Assembly resolution 58/23 of 25 May 2005.
The guidelines focus on manual wheelchairs and the needs of long-term wheelchair users. The
recommendations are targeted at those involved in wheelchair services, ranging from design andplanning, to providing or supplying wheelchairs and their maintenance.
The guidelines are divided into five chapters:
1. Introduction
2. Design and production
3. Service delivery
4. Training
5. Policy and planning&#>cigdYjXi^dc
The introductory chapter describes the need for and benefits of wheelchairs, types of wheelchairs,
and systems for their provision. It also defines the requirements of adequate wheelchairs andintroduces the reader to the stakeholders and their roles.
A wheelchair must meet the user’s individual needs and environmental conditions, provide
postural support, and be safe and durable. The wheelchair must be available and affordable andbe maintainable and sustainable in the country of use. This is not always easy, because wheelchairusers are a diverse group with different requirements and environmental and socioeconomic
conditions.
The chapter argues that a wheelchair is more than an assistive device for many people withdisabilities; it is the means by which they can exercise their human rights and achieve inclusionand equal participation. A wheelchair provides mobility, ensures better health and quality of life,
and assists people with disabilities to live full and active lives in their communities.

'#9Zh^\cVcYegdYjXi^dc
Chapter 2 sets out guidelines on the design and selection of wheelchairs and how to produce andsupply them. The focus here is to increase the quality and range of manual wheelchairs available inless-resourced settings. Health and safety, strength and durability, suitability for use, and effective
production methods are the main design criteria. The design of a wheelchair determines its
functional performance in matters of stability, manoeuvrability, pushing and transferring efficiency,transport and reliability.

1 0 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

The guidelines address the design process, including the need for product testing, field trials andlong-term follow-up. The need to involve wheelchair users in the design process is highlighted, as
they are the most knowledgeable about their physical, environmental, social and cultural needs.
Minimum guidelines and corresponding evaluation methods are given in the areas of functional
performance, seating and postural support elements, and strength and durability.
Governments are encouraged to develop and adopt national wheelchair standards to ensure areasonable level of quality, for instance by using the ISO 7176 series of wheelchair standards asa basis.

(#HZgk^XZYZa^kZgn
In this chapter, structural guidelines for systems that provide wheelchairs and that improve accessto wheelchairs are described. The need to provide wheelchairs together with other related services
is shown to be essential. Careful planning and management of services and well-thought-out
strategies for wheelchair provision, user instruction and care are needed to facilitate the important
link between the user and the wheelchair.
Guidelines in this chapter look at good practice at all stages of the service delivery process, fromreferral to assessment and prescription, funding, ordering, product preparation, fitting, user
training and maintenance. The chapter includes a discussion of the roles of those involved inwheelchair service delivery, from manufacturers and clinicians to technical and training personnel.
Recommendations are made on monitoring, how to obtain feedback from wheelchair users, andevaluating and analysing information on wheelchair service delivery.

)#IgV^c^c\
Chapter 4 looks at training requirements for those involved in the delivery of wheelchair services,with the aim of improving the level of skill of local people providing these services. Strategies areprovided for identifying trainers, linking to existing training programmes, developing modular
training packages, and capacity building at the local level. The guidelines set out the training
requirements for those involved in referral networks, managers of wheelchair services, and clinicaland technical personnel at basic and intermediate levels.

*#Eda^XnVcYeaVcc^c\
Chapter 5 looks at the role of policy and policy-makers in wheelchair provision, with a special
focus on cost-effectiveness and sustainability. Suggestions are made about financing options andways of linking wheelchair services to other sectors. A national policy on wheelchair provision
is recommended, with mechanisms for monitoring and evaluation, to ensure that users receive
wheelchairs that meet minimum requirements for safety, strength and durability and are appropriate
for their individual needs. Such a policy would look at need assessment, planning at the national
level, collaboration among service providers, the integration of wheelchair services with existing
rehabilitation services, and the adoption of national standards, with the aim of empowering users
and their families and facilitating user participation in community life.

EXECUTIVE SUMMARY

IZgb^cdad\nFor the purpose of these guidelines, the following terms are used in this document as defined
below.
wheelchaira device providing wheeled mobility and seating support for a person with diﬃculty in walking
or moving aroundless-resourced
settinga geographical area with limited ﬁnancial, human and infrastructural resources to provide
wheelchairs (a common situation in low- and middle-income countries, but also in certain areasof high-income countries)

manual wheelchaira wheelchair that is propelled by the user or pushed by another person

appropriate
wheelchaira wheelchair that meets the user’s needs and environmental conditions; provides proper ﬁt
and postural support; is safe and durable; is available in the country; and can be obtained andmaintained and services sustained in the country at the most economical and aﬀordable pricewheelchair usera person who has diﬃculty in walking or moving around and uses a wheelchair for mobility

personal mobility

the ability to move in the manner and at the time of one’s own choicewheelchair provisionan overall term for wheelchair design, production, supply and service delivery

wheelchair service

that part of wheelchair provision concerned with providing users with appropriate wheelchairs

I 1167DJII=:<J>9:A>C:H… on provision of manual wheelchairsin less-resourced settings.

This part of the guidelines:t outlines the purpose and scope of the guidelinest presents the target readerst describes the structure of the guidelines

I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

Box 1.

Wheelchairs changing lives …
Testimonial from a user in Colombia
Franber is an eight-year-old boy
who lives in Medelline, Colombia. He
cannot walk and his normal growth isaffected.
Franber used to spend his daysin bed while his mother worked
around the house. One day hereceived a wheelchair through a
local organization. He can now movearound and – best of all – he can go
to school and enjoy breaks with hisclassmates.

testimonial

ABOUT THE GUIDELINES

EjgedhZ
The Convention on the Rights of Persons with Disabilities and its Optional Protocol (1) were adopted
by the United Nations General Assembly on 13 December 2006 to promote, protect and ensure
the full and equal enjoyment of all human rights and fundamental freedoms by all persons withdisabilities, and to promote respect for their inherent dignity.
Articles 20 and 26 of the Convention affirm that States Parties (i.e. governments or authorities) shalltake effective measures to ensure personal mobility and rehabilitation by facilitating access to goodquality mobility aids, devices and assistive technologies at an affordable cost, and to encourage
entities that produce mobility aids, devices and assistive technologies.
Wheelchairs are the most common assistive or mobility devices for enhancing mobility with
dignity. Besides the Convention, these guidelines are an expression of WHO’s commitment at the
Fifty-eighth World Health Assembly to provide support to Member States in building up a systemfor producing, distributing and servicing assistive devices (2). WHO gives priority to the provisionof affordable assistive devices of good quality.
The goals of these guidelines are:t to promote personal mobility with the greatest possible independence for people withdisabilities;t to enhance the quality of life of users in less-resourced settings through improved access towheelchairs; andt to assist Member States in developing a system for wheelchair provision in support of Articles 4,
20 and 26 of the Convention and of Health Assembly resolution WHA58.23 of 25 May 2005.

HXdeZ
These guidelines focus on manual wheelchairs and the needs of long-term users. Some of therecommendations in the guidelines, however, are equally applicable to other types of mobility aid
or device (such as hand-powered tricycles) and for other types of user (such as temporary users). In
these guidelines, “wheelchair” means “appropriate manual wheelchair” unless otherwise indicated.
The guidelines have been developed for use in less-resourced settings.
This document is not a wheelchair manual. The scope is limited to addressing key areas – not
all aspects – of wheelchair provision, focusing on the design, production and distribution ofwheelchairs, wheelchair services, and training of related personnel. The recommendations are notintended to be comprehensive or prescriptive. Flexibility is required, owing to the many different
contexts in which they may be applied and implemented.

I 15

1 6 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

IVg\ZigZVYZgh
The intended readers include:
t government and nongovernmental policy-makers;
t planners, managers, providers and users of wheelchair services;t designers, testers, donors, purchasers and adapters of wheelchairs;t planners and managers of wheelchair production;t planners, developers and implementers of training programmes;
t developers of communication and advocacy materials;
t disabled people’s organizations;t groups of users; andt individual users and their families.

HigjXijgZThe guidelines are presented in five chapters.
1. The Introduction gives an overview of the need for wheelchairs, users of wheelchairs, types ofwheelchair, wheelchair provision and stakeholders.
2. Design and production provides recommendations on how to design, evaluate and selectwheelchairs.
3. Service delivery suggests the tasks and structure of a system for providing wheelchair services.
4. Training provides assistance in the design, development and implementation of training
opportunities for personnel involved in wheelchair provision.
5. Policy and planning provides information to guide decisions on wheelchair provision.

9ZkZadebZciegdXZhh
Following consultations with a wide range of stakeholders, WHO formed a small task force todevelop the guidelines, contracting Johan Borg as editorial consultant and coordinator of the group.
The main areas of the work were divided among various interested groups and their respective
partners from developing countries. Whirlwind Wheelchair International accepted responsibility
for the “Design and production” section, the Center for International Rehabilitation for “Service
delivery” and the Motivation Charitable Trust for “Training”.
More than 25 wheelchair experts took part in the development of the guidelines. A complete draft of
all the sections was prepared for a three-day discussion and review at WHO headquarters in Geneva
on 28–30 August 2006. Further revisions and external reviews took place during the two months
preceding the International Society for Prosthetics and Orthotics (ISPO) Consensus Conference on
Wheelchairs for Developing Countries, and a third draft was presented during the Conference forfurther feedback in Bangalore on 6–11 November 2006 (3).

ABOUT THE GUIDELINES

Following the ISPO Consensus Conference, the guidelines were further revised to reflect thediscussion and consensus reached at the Conference. They were then peer reviewed by 21
wheelchair experts, whose views were considered in finalizing the document. WHO also collected
the Declaration of Interests(DOI) from all the experts involved in the development of this document
and none of them declared any kinds of Conflicts of Interests with the subject matters.
These guidelines were approved by the WHO’s Guidelines Review Committee on 16 April 2008,
having met the minimum reporting requirements in place at that time. It is anticipated that therecommendations in this guideline will remain valid until 2013. The Department of Violence andInjury Prevention and Disability at WHO headquarters in Geneva will be responsible for initiating
a review of this guideline at that time.

GZ[ZgZcXZh
1.
2.
3.

Convention on the Rights of Persons with Disabilities. New York, United Nations (http://www.un.org/disabilities/default.
asp?id=259, accessed 6 March 2008).
Resolution WHA58.23. Disability, including prevention, management and rehabilitation. Geneva, World Health Organization,2005 (http://www.who.int/disabilities/publications/resolution/en/index.html, accessed 6 March 2008).
Sheldon S, Jacobs NA, eds. Report of a Consensus Conference on Wheelchairs for Developing Countries, Bangalore, India,
6–11 November 2006. Copenhagen, International Society for Prosthetics and Orthotics, 2007 (http://homepage.mac.com/
eaglesmoon/WheelchairCC/WheelchairReport_Jan08.pdf, accessed 8 March 2008).

I 17



1

>CIGD9J8I>DC… to promote personal mobility and enhance quality of life.

The introduction to the guidelines:
t defines an appropriate wheelchair;t introduces users;t points out the needs for and rights towheelchairs;t describes the benefits of wheelchairs;t describes basic types of wheelchair and common
systems of wheelchair provision; andt describes different stakeholders and their roles inwheelchair provision.

I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

Box 1.1.

Wheelchairs to enhance quality of life …
Testimonial from a user in Afghaanistan
Zahida lives in Afghanistaan,
in a tent in her brother’syard. She became paraple
egic
in 2001, but has had twochildren since then. She
was referred to a hospital
outpatient physiotherapyy
department in Jalalabad
and arrived pushed ina wheelbarrow. The
physiotherapists worked
with the technicians of a
local wheelchair workshop toprovide Zahida with a threeewheel wheelchair.
Without a wheelchair, Zah
hidacould do very little at hommewithout the help of her
husband and children. She
just lay on the bed. Her wheelchair has enabled her to successfully look after her children
in a very rough and hilly compound. Zahida says, “My wheelchair – it is like my feet – I
won’t go anywhere witho
out it! With my wheelchair I can cook, make bread, visit theneighbours. When we go to a family wedding in the village I take it with me in the back of
the taxi. My older daughte
er and son help to push me up the steep places.”

testimonial

INTRODUCTION

I 21&#&6eegdeg^ViZl]ZZaX]V^gh
These guidelines focus on appropriate manual wheelchairs. Manual wheelchairs are here defined
as wheelchairs propelled by the user or pushed by another person. A wheelchair is appropriate
when it (1):t meets the user’s needs and environmental conditions;t provides proper fit and postural support;t is safe and durable;t is available in the country: andt can be obtained and maintained and services sustained in the country at an affordable cost.
Throughout these guidelines, the term “wheelchair” means “appropriate manual wheelchair” unlessotherwise indicated.

&#'JhZghd[l]ZZaX]V^gh
In these guidelines, the term “users” refers to people who already use a wheelchair or who canbenefit from using a wheelchair because their ability to walk is limited. Users include:t children, adults and the elderly;t men and women and girls and boys;t people with different neuromusculoskeletal impairments, lifestyles, life roles and socioeconomic
status; andt people living in different environments, including rural, semi-urban and urban.
Users represent a wide range of mobility needs, but they have in common the need for a wheelchair
to enhance their mobility with dignity.

&#(CZZY[dgl]ZZaX]V^gh
About 10% of the global population, i.e. about 650 million people, have disabilities (2). Studies
indicate that, of these, some 10% require a wheelchair. It is thus estimated that about 1% of a total
population – or 10% of a disabled population – need wheelchairs, i.e. about 65 million people
worldwide.
In 2003, it was estimated that 20 million of those requiring a wheelchair for mobility did not haveone. There are indications that only a minority of those in need of wheelchairs have access to them,and of these very few have access to an appropriate wheelchair (1).

&#)G^\]ihidl]ZZaX]V^gh
States Parties to the Convention on the Rights of Persons with Disabilities have the obligation “totake effective measures to ensure personal mobility with the greatest possible independence for
persons with disabilities”. This is a commitment to provide mobility aids, such as wheelchairs, that1

2 2 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

make personal mobility possible. In 1993, the Standard Rules on the Equalization of Opportunities
for Persons with Disabilities (3) expressed the same commitment, demanding that countries
ensure the development, production, distribution and servicing of assistive devices for people
with disabilities in order to increase their independence and to realize their human rights.
These two important international declarations create rights to wheelchairs because it is universally
recognized that an appropriate wheelchair is a precondition to enjoying equal opportunities andrights, and for securing inclusion and participation. Personal mobility is an essential requirement
to participating in many areas of social life, and wheelchairs are for many the best means ofguaranteeing personal mobility.
Independent mobility makes it possible for people to study, work, participate in cultural life andaccess health care. Without wheelchairs, people may be confined to their homes and unable to live
a full and inclusive life. We know that eliminating world poverty is not possible unless the needsof those with disabilities are taken into account. Without wheelchairs, these individuals are unable
to participate in those mainstream developmental initiatives, programmes and strategies that are
targeted to the poor, such as are embodied in the Millennium Development Goals (4), the Poverty
Reduction Strategies (5) and other national developmental initiatives.
It is a vicious circle: lacking personal mobility aids, people with disabilities cannot leave the poverty
trap. They are more likely to develop secondary complications and become more disabled, andpoorer still. If they are children they will be unable to access the educational opportunities available
to them, and without an education they will be unable to find employment when they grow up
and will be driven even more deeply into poverty.
On the other hand, access to appropriate wheelchairs allows people with disabilities to work andparticipate in mainstream development initiatives that will reduce their poverty (see Fig.1.1.).
Similarly, a wheelchair can enable a child to go to school, to gain an education and, when the timecomes, to find a job (see Fig.1.2.).

Fig. 1.1. User at work

Fig. 1.2. User at school

The right to a wheelchair must be an essential component of all international endeavours to secure
the human rights of people with disabilities.

INTRODUCTION

I 23&#*7ZcZÒihd[l]ZZaX]V^gh
Wheelchair provision is not only about the wheelchair, which is just a product (6). Rather, it isabout enabling people with disabilities to become mobile, remain healthy and participate fully incommunity life. A wheelchair is the catalyst to increased independence and social integration, but
it is not an end in itself (6–8) (see Fig.1.3.).

Fig.1.3. Participation in community life

The benefits of using an appropriate wheelchair include those outlined below.

=ZVai]VcYfjVa^ind[a^[Z
In addition to providing mobility, an appropriate wheelchair is of benefit to the physical healthand quality of life of the user. Combined with adequate user training, an appropriate wheelchair
can serve to reduce common problems such as pressure sores, the progression of deformities
or contractures, and other secondary conditions (9). A wheelchair with a proper cushion often
prevents premature death in people with spinal cord injuries and similar conditions and, in one
sense, is a life-saving device for these people. A wheelchair that is functional, comfortable andcan be propelled efficiently can result in increased levels of activity. Independent mobility andincreased physical function can reduce dependence on others. Other benefits, such as improved
respiration and digestion, increased head, trunk and upper extremity control and overall stability,
can be achieved with proper postural support. Maintenance of health is an important factor inmeasuring quality of life. These factors combined serve to increase access to opportunities foreducation, employment and participation within the family and the community.

1

2 4 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S:Xdcdbn
A wheelchair often makes all the difference between being a passive receiver and an active
contributor. Economic benefits are realized when users are able to access opportunities foreducation and employment. With a wheelchair, an individual can earn a living and contribute to
the family’s income and national revenue, whereas without a wheelchair that person may remain
isolated and be a burden to the family and the nation at large. Similarly, a wheelchair that is notdurable will be more expensive owing to the need for frequent repairs, absence from work andeventual replacement of the wheelchair. Providing wheelchairs is more cost-effective if they last
longer (10). It is also more cost-effective if users are involved in selecting their devices and if theirlong-term needs are considered (11).
For society, the financial benefits associated with the provision of wheelchairs include reduced
health care expenses, such as those for treating pressure sores and correcting deformities. A study
from a developing country reported that in 1997, 75% of those with spinal cord injuries admitted tohospital died within 18–24 months from secondary complications arising from their injuries. In thesame place, the incidence of pressure sores decreased by 71% and repetitive urinary tract infections
fell by 61% within two years as a result of improvements in health care training and appropriate
equipment, including good wheelchairs with cushions (12).

&#+8]VaaZc\Zh[dgjhZgh
Users face a range of challenges, which must be considered when developing approaches towheelchair provision.

;^cVcX^VaWVgg^Zgh
Some 80% of the people with disabilities in the world live in low-income countries. The majorityof them are poor and do not have access to basic services, including rehabilitation facilities (13).
The International Labour Organization (ILO) reports that the unemployment rates of people withdisabilities reach an estimated 80% or more in many developing countries (14). Government funding
for the provision of a wheelchair is rarely available, leaving the majority of users unable to pay fora wheelchair themselves.

E]nh^XVaWVgg^Zgh
As many users are poor, they live in small houses or huts with inaccessible surroundings. They
also live where road systems are poor, there is a lack of pavements, and the climate and physicalterrain are often extreme. In many contexts, public and private buildings are difficult to access ina wheelchair. These physical barriers place additional requirements on the strength and durabilityof wheelchairs. They also require that users exercise a high degree of skill if they are to be mobile.

INTRODUCTION

I 25

6XXZhhidgZ]VW^a^iVi^dchZgk^XZh
In many developing countries, only 3% of people with disabilities who require rehabilitation services
have access to them (15). According to a report of the United Nations Special Rapporteur (16), 62
countries have no national rehabilitation services available to people with disabilities. This meansthat many wheelchair users are at risk of developing secondary complications and premature deaththat could be avoided with proper rehabilitation services. In many countries, wheelchair service
delivery is not included in the national rehabilitation plan.

:YjXVi^dcVcY^c[dgbVi^dc
Many users have difficulty in accessing relevant information, such as on their own health conditions,prevention of secondary complications, available rehabilitation services and types of wheelchairavailable. For many, a wheelchair service may be their first access to any form of rehabilitation
service. This places even more emphasis on the importance of user education.

8]d^XZ
Users are rarely given the opportunity to choose the most appropriate wheelchair. Often there is
only one type of wheelchair available (and often in only one or two sizes), which may not be suited
to the user’s physical needs, or practical in terms of the user’s lifestyle or home or work environment.
According to the Convention on the Rights of Persons with Disabilities, “States Parties shall takeeffective measures to ensure personal mobility with the greatest possible independence for persons
with disabilities … by facilitating the personal mobility of persons with disabilities in the mannerand at the time of their choice, and at affordable cost” (17).

&#,L]ZZaX]V^gegdk^h^dc
Wheelchair provision usually includes the design, production and supply of wheelchairs and deliveryof wheelchair services.

Fig. 1.4. Overview of wheelchair provision

DESIGNp
PRODUCTIONp
SUPPLYp
SERVICEDELIVERYp1

2 6 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

Wheelchair provision can only enhance a wheelchair user’s quality of life if all parts of the process
are working well. This includes ensuring users have access to:t wheelchairs of an appropriate design;t wheelchairs that have been produced to appropriate standards;
t a reliable supply of wheelchairs and spare parts; andt wheelchair services that assist the user in selecting and being fitted with a wheelchair, provide
training in its use and maintenance, and ensure follow-up and repair services.
Personnel involved in each area of wheelchair provision need to have the correct skills andknowledge. This means that training is essential for those involved in wheelchair provision.

9Zh^\c!egdYjXi^dcVcYhjeean
The design of a wheelchair depends on a number of factors:
t the physical needs of users;t the way and the environment in which the wheelchair will be used; andt the materials and technology available where the wheelchair is made and used.
Wheelchairs can be produced in the country or outside the country. Those produced outside
the country are often mass produced and imported as new or used wheelchairs. Wheelchairs
can be supplied to wheelchair service providers by manufacturers, agents or distributors, or byorganizations specializing in wheelchair supply.
Information on design, production and supply is provided in Chapter 2.

HZgk^XZYZa^kZgn
Appropriate provision of wheelchairs is most important in the successful rehabilitation of people
who need a wheelchair for mobility. Historically, however, wheelchair service delivery has not been
an integral part of rehabilitation services. This is due to many factors, including poor awareness,
scarce resources, a lack of appropriate products, and a lack of training for health and rehabilitation
personnel in wheelchair service delivery.
In many countries, users depend on charity or external donations. Donated wheelchairs are often
inappropriate and of poor quality, giving further problems for the user and for the country in thelong run. Users are not in a position to demand good quality from charities. A study in India revealed
that 60% of wheelchair users who had received donated wheelchairs stopped using them owing
to discomfort and the unsuitability of the wheelchair design for the environment in which it wasused (18).
The result is that many people who require a wheelchair do not receive one at all, while those who
do often get one without any assessment, prescription, fitting and follow-up. Many users, evenpeople with spinal cord injury, often get wheelchairs without a cushion or basic instructions, which
can lead to pressure sores and even premature death.
There is, however, increasing awareness of the importance of providing individual assessment,
fitting and training in how to use a wheelchair. In a number of less-resourced settings, wheelchair
services have been established using different models of service delivery. Such models include

INTRODUCTION

I 27

centre-based or community-based services, outreach services, mobile “camp”-style services anddonations of imported wheelchairs. In countries where user groups are well informed and service
providers have the necessary knowledge and support, wheelchair services are becoming integrated
into existing rehabilitation activities. The common aim is to ensure that users are given skilledassistance in selecting the most appropriate wheelchair for their needs.
Information on wheelchair services is provided in Chapter 3.

IgV^c^c\
In less-resourced settings, limited training opportunities result in few people being trained to
manage the provision of wheelchairs and other assistive devices. Scarcity of trained personnel toassist in choosing and obtaining a wheelchair becomes a barrier to participation (19).
Existing courses for health and rehabilitation professionals provide little input on wheelchair
service delivery and related issues. In some instances, national personnel may have had informal
training from expatriate personnel, but such training is often limited to the products available inthe country and the trainer’s own experience and abilities. If the training is not recorded it is not
replicable, and the resulting skill levels are not measurable. It is difficult for local personnel tocontinue practising skills derived from this type of informal training once the trainers and originalusers leave the service.
The lack of formal training has resulted in a lack of recognition of specialist skills in wheelchair
provision. In an attempt to address these needs, some initiatives have been taken by development
organizations.
Detailed information on training is provided in Chapter 4.

&#-IneZhd[l]ZZaX]V^g
No single model or size of wheelchair can meet the needs of all users, and the diversity among users
creates a need for different types of wheelchair. Those selecting wheelchairs, in consultation withthe user, need to understand the physical needs of the intended user and how he or she intends
to use the wheelchair, as well as knowledge of the reasons for different wheelchair designs.

I]Ze]nh^XVacZZYhd[jhZgh
The ability to adjust or customize a wheelchair to meet the user’s physical needs will vary, dependingon the type of wheelchair. Often, wheelchairs are available in at least a small range of sizes andallow some basic adjustments.
Wheelchairs designed for temporary uses (for example, to be used in a hospital to move patientsfrom one ward to another) are not designed to provide the user with a close fit, postural support
or pressure relief. Orthopaedic or “hospital” wheelchairs are an example of this type (see Fig. 1.5).

1

2 8 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

Fig. 1.5. Wheelchair designed for
temporary user

Fig. 1.6. Wheelchair designed forlong-term user

Fig. 1.7. Wheelchair designed foruser with postural support needs

For long-term users, a wheelchair must fit well and provide good postural support and pressure
relief (Fig. 1.6). A range of seat widths and depths, and the possibility to adjust at least the footrest
and backrest height are important in ensuring that the wheelchair can be fitted correctly. Other
common adjustments and options include cushion types, postural supports and an adjustablewheel position.
Highly adjustable or individually modified wheelchairs are designed for long-term users withspecial postural needs (Fig. 1.7). Such wheelchairs often have additional components added tohelp support the user.

=dli]Zl]ZZaX]V^g^hjhZY
Wheelchair designs vary to enable users to safely and effectively use their wheelchair in theenvironment in which they live and work.
A wheelchair that is used primarily in rough outdoor environments needs to be robust, morestable and easier to propel over rough ground. Fig. 1.8 illustrates an example of a three-wheeled
wheelchair that would be well suited to outdoor use. In comparison, a wheelchair that is usedindoors on smooth surfaces needs to be easy to manoeuvre in small indoor spaces.

INTRODUCTION

Fig. 1.8. Wheelchair suitable for outdoor use

I 29

Fig. 1.9. Wheelchair suitable for indoor andoutdoor use

1
Many users live and work in a range of settings, and a compromise is therefore often necessary.
Fig. 1.9 shows a robust wheelchair with a relatively short wheelbase but large castor wheels. This
wheelchair could be used both indoors and outdoors.
Users need to be able to get in and out of the wheelchair easily, to propel it efficiently and to repair
it. Users may need to transport their wheelchair, for example in a bus or car (Fig. 1.10). Different
wheelchair designs allow for wheelchairs to be made more compact in different ways. Some arecross-folding (Fig. 1.10), while others have quick-release wheels (Fig.1.11. and Fig.1.12.) and thebackrest folds forwards.

Fig. 1.10. Folding wheelchair

Fig. 1.11. Quick-release wheels

Fig. 1.12. Detachable wheels

These needs and their related wheelchair design features are discussed in Chapter 2.

3 0 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

BViZg^VahVcYiZX]cdad\nVkV^aVWaZ
Wheelchair designs vary, depending on the materials and technology available for production andrepair, For example, wheelchair designers must take into account the strength and variability of
the available materials to avoid premature failure. In the case of failure, the wheelchair should be
easily repairable (20). See Chapter 2 for more information on this topic.

&#.HiV`Z]daYZghVcYi]Z^ggdaZh&#.#&Eda^XneaVccZghVcY^beaZbZciZgh
Policy planners and implementers are directly involved in the planning, initiation and ongoing
financial, advisory and legislative support of wheelchair provision. The role of policy planners
includes the following.
t Wheelchair provision policy is developed in consultation with other stakeholders, aiming at
effective measures to ensure personal mobility with the greatest possible independence forpeople with disabilities. This includes:t GBDJMJUBUJOH UIF QFSTPOBM NPCJMJUZ JO UIF NBOOFS BOE BU UIF UJNF PG UIFJS DIPJDF BOE BU BO
affordable cost;t BDDFTTUPXIFFMDIBJST JODMVEJOHNBLJOHUIFNBWBJMBCMFBUBOBòPSEBCMFDPTUt QSPWJEJOHUSBJOJOHJONPCJMJUZTLJMMTUPQFPQMFXJUIEJTBCJMJUJFTBOEUPSFIBCJMJUBUJPOQFSTPOOFMandt FODPVSBHJOHFOUJUJFTUIBUQSPEVDFXIFFMDIBJSTBOEPUIFSNPCJMJUZBJETXJUIJOUIFDPVOUSZt Standards for wheelchair products, service delivery and training are adopted, promoted andenforced.
t Measures are taken to ensure that wheelchair provision is equitable and accessible to all, including
women and children, the poorest and those in remote areas.
t Wheelchair services are developed as an integral part of health care structures and in coordination
with associated services, such as rehabilitation, prosthetic, orthotic and community-based
rehabilitation services.
t Sustainable funding policies for wheelchair provision are developed.
t Wheelchair user groups and disabled peoples’ organizations are involved at every stage fromplanning to implementation.
According to United Nations Standard Rules and the Convention, it is the primarily responsibilityof countries to make wheelchairs available at an affordable cost. Ensuring the availability ofwheelchair services within a country does not necessarily mean the direct provision of services
by the government. Nevertheless, the government can work closely with nongovernmental andinternational nongovernmental organizations, development agencies, user groups and the private
sector to develop national policies and a provision system. Furthermore, in developing the policy
one needs to ensure that wheelchair services are cohesive and closely linked with national healthand rehabilitation strategies.

INTRODUCTION

I 31

Box 1.2. Wheelchair provision and government ministries
Which ministry is typically responsible for wheelchair provision?
Wheelchair provision impacts on a number of government ministries and authorities. Ministries of health are generally
responsible for health care and rehabilitation services, and therefore have a primary responsibility for wheelchair
provision. In some countries, however, other ministries take a leading role. In India, wheelchair services are provided by
the Ministry of Social Justice and Empowerment and in Ghana by the Ministry of Labour and Social Welfare. In Kenya, aconsortium of the Ministry of Health, social welfare services and nongovernmental organizations facilitates wheelchair
service delivery within the country. Other ministries can also play a role, as the needs of users include economic andsocial issues that may be addressed by the ministry of social welfare or similar.
Ministries responsible for employment and education have a role in ensuring the rights of wheelchair users. Thus,
unless the responsible ministries or authorities ensure that wheelchair users have access to buildings and public
transport, they will not be able to participate in educational, economic and social activities.

&#.#'BVcj[VXijgZghVcYhjeea^Zgh
An organization may be involved in one or more of the areas of manufacturing and supplying
wheelchairs. Supplying means delivering wheelchairs to service providers, either through sale or
donation. The role of manufacturers and suppliers of wheelchairs is to develop, produce or supply
wheelchairs that meet the needs of users in different contexts. This includes:t manufacturing or supplying products that are appropriate for the use to which they will beput;t ensuring their products meet or exceed relevant wheelchair standards;
t providing wheelchairs through wheelchair services that offer, as a minimum, assessment, fitting,user training and follow-up; andt ensuring that wheelchairs can be repaired locally.
Irrespective of the service model used to provide wheelchairs, it is recommended that suppliers
exercise their responsibility by ensuring that:t the service provider has the capacity to provide the supplied wheelchairs in a reasonable andresponsible manner; andt the supply is based on an assessment of the situation in the country or region and considers theimpact on local manufacturers and service providers.

&#.#(L]ZZaX]V^ghZgk^XZhWheelchair services provide the essential link between the users and the manufacturers andsuppliers of wheelchairs. Service providers include:
t government wheelchair services
t nongovernmental organizations that provide such services
t the private sectort hospitals and public health centres.

1

3 2 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

The main role of a wheelchair service is to assist users to choose the most appropriate wheelchair,
to ensure that it is adjusted or modified to suit their individual needs, to train users, and to provide
follow-up and maintenance services. Service providers also play a role in:t giving feedback to manufacturers and suppliers about wheelchair design;
t developing referral networks; andt developing and finding sustainable funding sources for wheelchairs and services.

&#.#)Egd[Zhh^dcVa\gdjehRehabilitation is a question of teamwork. Professionals such as therapists, health/nursing personnel,
orthotists/prosthetists, physiatrists and others can play a major role in providing quality services,training personnel as well as users, enhancing the quality of life of the users, and sharing anddocumenting best practices. A team comprising all groups of rehabilitation personnel can ultimately
benefit the user and has in particular proven useful in the development of the new profession or
discipline of wheelchair provision. More professional groups need to be involved in wheelchair
provision in less-resourced settings. A good example of such involvement is the International
Society for Prosthetics and Orthotics (ISPO), which has supported the development of structured
professional training for wheelchair technologists.
The role of professional groups includes:
t guiding and supporting the activities of those responsible for wheelchair services;t advancing the practice and standards of wheelchair service delivery;t facilitating the placement and secondment of wheelchair professionals;
t facilitating the exchange of information; andt promoting the education and training of wheelchair professionals.
Box 1.3. Wheelchair industry association in Africa
In Africa, the Pan Africa Wheelchair Builders Association represents those involved in wheelchair design, production,
funding and distribution. The Association was formed following a meeting of African wheelchair producers in Zambia
in 2003 and is now established in Moshi, United Republic of Tanzania. One of its main activities is networking among
wheelchair builders to support each other and to share resources.

&#.#*>ciZgcVi^dcVacdc\dkZgcbZciVadg\Vc^oVi^dch
International nongovernmental organizations are often involved in facilitating wheelchair provision
where there is little or no national service delivery. The policies and practices of these organizations
should promote coordinated wheelchair provision that is equally accessible to all.
The role of international nongovernmental organizations in wheelchair provision includes:
t meeting the immediate needs of users where local wheelchair provision is lacking;t supporting the state to fulfil its obligations concerning wheelchair provision;t assisting the national authorities to develop a proper wheelchair service delivery system within
the country;

INTRODUCTION

I 33

t ensuring their activities are part of a broader long-term strategy acknowledged and supported

by relevant authorities (e.g. the government);t building the capacities of disabled people’s organizations in accessing wheelchairs and developing

partnerships;
t facilitating links between the various stakeholders – users, wheelchair service providers andgovernments;
t implementing wheelchair services by providing training expertise where none is available locally,and building capacities for both the technical and organizational aspects of wheelchair service
delivery; andt establishing services or pilot projects that include best practices for replication by governmental,
nongovernmental and international nongovernmental organizations.

&#.#+9^hVWaZYeZdeaZÉhdg\Vc^oVi^dch
Disabled people’s organizations have a crucial role to play in the planning, initiation and ongoingsupport of wheelchair service delivery. As organizations, they are able to advocate more effectively
than individuals for users’ needs.
To be effective, disabled people’s organizations need knowledge and experience with appropriate
products and services. Such organizations played an important role in preparing the Convention on
the Rights of Persons with Disabilities and will continue to be involved in its implementation in the
future. Wheelchair users have an important role to play in implementing Article 20 of the Convention
concerned with personal mobility and of Article 26 addressing habilitation and rehabilitation.
The role of disabled people’s organizations in wheelchair provision includes:
t defining user’s needs and barriers to equal participation;t raising awareness of the need for effective wheelchair provision and financing;t consulting with policy planners and implementers in the development of wheelchair services;t raising awareness of wheelchair services, and identifying people who need wheelchairs andlinking them with wheelchair services;t monitoring and evaluating wheelchair services;t advocating against inappropriate wheelchair provision, and that wheelchair services comply
with agreed guidelines; andt supporting users by providing peer support and training.

1

3 4 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S&#.#,JhZgh![Vb^a^ZhVcYXVgZ\^kZgh
Users and their groups are at the centre of developing and implementing wheelchair provision(Fig.1.13). They can help ensure that wheelchair services meet their needs effectively.

Fig. 1.13. Users group

The role of users includes:t participating in the planning, implementation, management and evaluation of wheelchair
provision;t participating in the development and testing of wheelchair designs;
t working within wheelchair services in clinical, technical and training roles; andt supporting and training new users.
Some users permanently rely on members of their family to assist with day-to-day activities ofliving, while others may be more independent. Where a family member or caregiver is responsible
for assisting a user on a daily basis, such as a parent of a child with cerebral palsy, he or she should
also be involved in all the roles listed above for users.
Family groups for parents, siblings and other relatives of children with disabilities are encouraged
to undertake the activities listed under in Section 1.9.6.
Box 1.4. Wheelchair user at policy and implementation level in Uganda

In Uganda, a wheelchair provision stakeholders’ meeting was held in 2004, hosted by the Ministry of Health andsponsored by the Norwegian Association for the Disabled. This allowed users, disabled people’s organizations,producers, government departments and donors to contribute their perspectives on the current situation of wheelchair
provision, to agree on long-term goals, and to plan how to achieve them. The meeting led to the appointment of awheelchair user as Wheelchair Project Oﬃcer within the Ministry of Health. This person’s own experience has enriched
the process of wheelchair service development in the country by bringing a user’s perspective to the policy andimplementation level.

INTRODUCTION

I 35

HjbbVgnt About 1% of a population need a wheelchair.
t Rights to wheelchairs are outlined in the United Nations policy instruments “Convention on the

Rights of Persons with Disabilities” and “Standard Rules on the Equalization of Opportunities for
Persons with Disabilities”.
t Using an appropriate wheelchair benefits the health and quality of life of the user, and can leadto economic benefits for the user, the user’s family and society as a whole.
t Wheelchair provision includes the design, production and supply of wheelchairs and wheelchair
service delivery.
t When developing approaches to wheelchair provision, it is necessary to consider financial andphysical barriers for users, their access to rehabilitation services, and user education, informationand choice.
t There is a need for different types and sizes of wheelchair owing to the diversity of needs amongusers.
t Stakeholders involved in wheelchair provision include policy planners and implementers;
manufacturers, suppliers and donors of wheelchairs; providers of wheelchair services andprofessional groups; national and international nongovernmental organizations and disabled
people’s organizations; and users, their families and caregivers.

1

3 6 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

GZ[ZgZcXZh
1.

Sheldon S, Jacobs NA, eds. Report of a Consensus Conference on Wheelchairs for Developing Countries, Bangalore, India,
6–11 November 2006. Copenhagen, International Society for Prosthetics and Orthotics, 2007 (http://homepage.mac.com/
eaglesmoon/WheelchairCC/WheelchairReport_Jan08.pdf, accessed 8 March 2008).
2. Concept note. World Report on Disability and Rehabilitation. Geneva, World Health Organization, 2008 (http://www.who.int/
disabilities/publications/dar_world_report_concept_note.pdf, accessed 8 March 2008).
3. The Standard Rules on the Equalization of Opportunities for Persons with Disabilities. Preconditions for Equal Participation. New
York, United Nations, 1993 (http://www.un.org/esa/socdev/enable/dissre03.htm, accessed 8 March 2008).
4. Millennium Development Goals. New York, United Nations, 2000 (http://www.un.org/millenniumgoals, accessed 8 March
2008).
5. Poverty reduction strategies. Washington, DC, World Bank. 2007 (http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/
EXTPOVERTY/EXTPRS/0,,menuPK:384207~pagePK:149018~piPK:149093~theSitePK:384201,00.html, accessed 8 March
2008).
6. Krizack M. 2003. It’s not about wheelchairs. San Francisco, CA, Whirlwind Wheelchair International, 2003 (http://www.
whirlwindwheelchair.org/articles/current/article_c02.htm, accessed 8 March 2008).
7. Rushman C, Shangali HG. Wheelchair service guide for low-income countries. Moshi, Tanzanian Training Centre
for Orthopaedic Technology, Tumani University, 2005.
8. Rushman C et al. Atlas of orthoses and assistive devices: appropriate technologies for assistive devices, 3rd ed. Rosemont, IL,
American Academy of Orthopaedic Surgeons, 2006.
9. Howitt J. Patronage or partnership? Lessons learned from wheelchair provision in Nicaragua [thesis]. Washington, DC,
Georgetown University, 2005.
10. Fitzgerald SG et al. Comparison of fatigue life for 3 types of manual wheelchairs. Archives of Physical Medicine andRehabilitation, 2002, 82:1484–1488.
11. Phillips B, Zhao H. Predictors of assistive technology abandonment. Assistive Technology, 1993, 5:36–45.
12. Beattie S, Wijayaratne L. A study of the cost of rehabilitation of spinal cord injured patients in Sri Lanka. Colombo, Motivation,
1999 (http://www.motivation.org.uk/_history/History_SriLankaTotalRehab.htm, accessed 25 March 2008).
13. Disability and Rehabilitation Team (DAR). Geneva, World Health Organization, 2006 (http://www.who.int/disabilities/
introduction/en/, accessed 26 July 2006).
14. Time for equality at work. Global Report under the Follow-up to the ILO Declaration on Fundamental Principles and Rights at
Work. Geneva, International Labour Office, 2003 (http://www.ilo.org/dyn/declaris/DECLARATIONWEB.DOWNLOAD_BLOB/
Var_DocumentID=1558, accessed 8 March 2008).
15. Helander E. Prejudice and dignity: an introduction to community based rehabilitation, 2nd ed. New York, United Nations
Development Programme, 1999.
16. Global Survey on Government Action on the Implementation of the Standard Rules on the Equalization of Opportunities for Persons
with Disabilities. New York, United Nations, 2006 (http://www.un.org/disabilities/default.asp?navid=9&pid=183, accessed 8
March 2008).
17. Convention on the Rights of Persons with Disabilities. New York, United Nations (http://www.un.org/disabilities/default.
asp?id=259, accessed 6 March 2008).
18. Mukherjee G, Samanta A. Wheelchair charity: a useless benevolence in community-based rehabilitation. Disability andRehabilitation, 2005, 27:591–596.
19. Scherer MJ, Glueckauf R. Assessing the benefits of assistive technologies for activities and participation. Rehabilitation
Psychology, 2005, 50:132–141.
20. McNeal A, Cooper RA, Pearlman J. Critical factors for wheelchair technology transfers to developing countries – materials anddesign constraints. In: Proceedings of the 28th Annual RESNA Conference [CD-ROM]. Atlanta, GA, RESNA, 2005:25–27

2

9:H><C6C9EGD9J8I>DC… to increase the quality and range of wheelchairs.

This chapter:t outlines methods for designing or selecting awheelchair;t describes different types of wheelchair
production and supply;t sets out the advantages and disadvantages ofdifferent wheelchair designs; andt suggests how to describe and evaluate
wheelchairs in terms of functional performance;
seating and postural support; and strength,
durability and safety.

I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

Box 2.1.

Wheelchairs
ee c a s changing
c a g g lives
es …
Testimonial from a user in Cambodia
In 1982, Reth stepped on a landmine.
He later had both of his legs amputated.
He received vocational training at a Thai
refugee camp, where he stayed for
13 years. In 1993, Reth moved backto Cambodia and was employed andtrained as a wheelchair builder ina local wheelchair workshop. Rethhimself received a three-wheeled
active-style wheelchair and a tricycle
through the workshop.
The mobility provided by both
the wheelchair and the tricycle has
enabled Reth to work, care for his wife anddsix children, and become an active campaigner against
landmines. Reth is an ambassador for the International Campaign to Ban Landmines(ICBL), an initiative that was awarded the Nobel Peace Prize in 1997. He has travelled theworld urging governments to make landmines history.
Reth says: “I have to admit that what happened to me, being a landmine victim, helpedme realize that life does not end in one or more difficulties. Also, through the help of somany people around me I was able to go beyond the tragedy in my life. Now I am an
active spokesperson for ICBL. Whenever there’s an opportunity to speak about advocacy
to ban landmines, I make a sincere appeal to people and governments, asking them tosupport this campaign, to give more assistance to help the victims and their families.
Also, at present I am working in the Jesuit Service Cambodia – Siem Reap team, in thewheelchair team and outreach programmes. As of now, we are able to reach people in
222 villages, 90 communes and 12 districts. It is not an easy job for a double amputee,
but I am happily fulfilled.”

ttestimonialt

DESIGN AND PRODUCTION

I 39'#&>cigdYjXi^dc
EjgedhZVcYdjiejih
The purpose of the design and production guidelines is to increase the quality and range of manual
wheelchairs available in less-resourced settings.
Implementation of these guidelines will lead to:t a wider variety of wheelchair types and designs
t wheelchairs that are safe and meet minimum requirementst lower long-term costs of wheelchairst more available information about wheelchairst national standards for wheelchairs.
The guidelines have been developed to apply to manual wheelchairs with a variety of features.
These include all levels of adjustability, three- and four-wheeled wheelchairs, folding and rigid
wheelchairs, and adult and paediatric wheelchairs. While the guidelines are not written specificallyfor devices such as hand-powered tricycles, the principal recommendations may nevertheless beapplicable.
These guidelines can be used to design wheelchairs and select pre-existing wheelchair designs for
production and supply to wheelchair services.

HigViZ\^Zh
9Zh^\c
The aim of wheelchair design is to produce wheelchairs that perform well and can provide
appropriate seating and postural support without compromising strength, durability and safety.
This can be achieved when government authorities, manufacturers, engineers, designers, service
providers and users fulfil their respective roles with respect to design.

HiVcYVgYh
It is recommended that government authorities develop and adopt national wheelchair standards
applicable to all wheelchairs supplied in a country. This includes all locally produced wheelchairs
and imported wheelchairs, whether donated or purchased.
The International Organization for Standardization (ISO) has developed international standards
for wheelchairs, known as the ISO 7176 series (1). This series specifies a terminology and testing
methods for evaluating wheelchair performance, size, strength, durability and safety. Many national
standards committees have adopted the ISO 7176 series, or an individually tailored form of theseries, as their own wheelchair standards.
All requirements in the ISO 7176 series may not reflect typical conditions in less-resourced settings,
as some of the requirements were designed to simulate the conditions in city environmentswith smooth roads. When developing national standards, it is therefore important to consider
environments, the weights and sizes of users, typical uses, and the available wheelchair and allied
technologies (such as bicycle/tricycle) within the country.

2

4 0 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

EgdYjXi^dcVcYhjeean
Governments, manufacturers and suppliers need to work together to establish a sustainable supplyof wheelchairs that meet national standards. Whether produced in the country or imported, it isimportant that the range of wheelchairs meets the diverse needs of users.
Governments and organizations are encouraged to support manufacturers in using test equipment
to improve the quality of their wheelchairs, to make efforts to minimize the costs of testing for local
manufacturers, and to support the dissemination of wheelchair quality evaluations

8daaVWdgVi^dc
The resources needed to implement these guidelines can be minimized through joint planningand cooperation among government authorities, nongovernmental organizations, international
nongovernmental organizations, disabled people’s organizations, foreign governments, bilateral aid
agencies and the private sector. As much as possible, existing infrastructure and expertise should
be used, supported and further developed.

IgV^c^c\Individuals need to be trained to design, produce and test wheelchairs that meet these guidelines. Thiscan be done by introducing these guidelines to students or practitioners of related disciplines.

>c[dgbVi^dcXdaaZXi^dcVcYY^hhZb^cVi^dc
Wheelchair evaluation and testing results should be recorded and made available to all stakeholders.
Such information will help stakeholders to select the most appropriate wheelchair for a given use.
Service providers, users and advocacy groups are also encouraged to use the information provided
to communicate with wheelchair manufacturers and suppliers about their specific needs and how
available wheelchairs meet their needs.

HiV`Z]daYZghVcYgZhdjgXZhStakeholders involved in the design and production of wheelchairs include purchasers, manufacturers,
designers, evaluators and users. Experienced wheelchair users can often contribute substantially indesigning wheelchairs. Key resources required to implement the design and production guidelines
include:t engineers, designers, users, technicians and manufacturers
t product evaluators
t facilities and equipment to produce or assemble wheelchairst facilities and equipment to evaluate wheelchairs.

'#'L]ZZaX]V^gYZh^\c
Wheelchair designs vary greatly to take account of the diverse needs of users. To ensure wheelchairs
are appropriate, designers and providers must thoroughly understand the needs of the intended
users and their environments. Users’ needs are best met when there is a variety of models fromwhich to choose.
The names of common wheelchair parts are shown in Fig. 2.1. A cushion is to be considered an
integral part of a wheelchair, and is therefore to be included with all wheelchairs. People with spinal
cord injuries or similar conditions require pressure relief cushions that prevent the developmentof life-threatening pressure sores.

DESIGN AND PRODUCTION

I 41

Fig. 2.1. Example of a manual wheelchair and its parts

push handles

backrestarmrestrear wheels
cushionpush rings

seat
frame

brakescalf strap
footrest

castor wheels'#'#&<ZcZgVaXdch^YZgVi^dch^cl]ZZaX]V^gYZh^\c
Wheelchairs should be designed to enable their users to participate in as many activities as possible.
As a minimum, a wheelchair should enable the user to lead a more active life without having anegative effect on their health or safety. Comfort and safety are two important factors affecting
the quality of life of long-term users (2).

I]ZjhZgÉh]ZVai]VcYhV[Zin
The health and safety of users should never be compromised in order to reduce costs. Although it
may seem that any wheelchair is better than no wheelchair, this is not true when the wheelchaircauses or contributes to injury or other health risks.
A wheelchair should be designed to ensure the user’s safety and health. There are many ways inwhich users can be injured by their own wheelchairs, as illustrated by the following examples:t A wheelchair without a cushion or with an inadequate cushion can cause pressure sores. This inturn may require the user to spend many months in bed; without appropriate care and treatment
this often leads to bedsores, secondary complications and even premature death.
t Unstable wheelchairs can tip and lead to users falling and injuring themselves.
t Wheelchairs that are too wide or are unduly heavy can cause shoulder injuries.
t Sharp edges on surfaces can cause cuts that in turn can lead to infection.
t Poor design can result in places on the wheelchair where the user or others can get their fingers
or skin pinched.
t Wheelchairs that cannot endure daily use in the user’s environment may fail prematurely andcan injure the user.

2

4 2 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

HigZc\i]VcYYjgVW^a^in
Wheelchairs used outdoors are subjected to greater wear and tear than those designed for indoor
use or use on smooth roads and paths. A wheelchair must be strong enough not to suffer a sudden
failure while being used. The wheelchair should be built to have the longest possible useful life andrequire the fewest repairs. A wheelchair should be designed so it can be repaired near the user’s
home if it fails, and replacement parts should be easily available.

Hj^iVW^a^in[dgjhZWheelchairs should be appropriate for the environment in which they will be used and for the
specific people who will use them. One wheelchair design will not suit everyone. When designingor selecting wheelchairs, it is necessary to think about the environment and the way in which thewheelchair may be used (Box 2.2).
Box 2.2. Some environments and uses to consider when designing or selecting a wheelchair
Riding for long distances over rough roads.
Going up and down many kerbs every day.
Q
Accessing built environments: narrow
doorways, small turning areas, steep ramps,
desks and tables, bathroom facilities (e.g.
sitting and squatting toilets).
Q
Exposure to moisture such as rain, highhumidity, snow, ice, hail and body ﬂuids suchas urine and sweat.
Q
User showering while sitting in the wheelchair.
Q
Exposure to extreme temperatures.
Q
User transporting goods on the push handles,
upholstery, footrests or other parts of thewheelchair.
Q
Passengers riding on footrests and armrests.
Q
People lifting the wheelchair by one armrest,
footrest or push handle when the wheelchair is
occupied.
Q
Transporting the wheelchair in conﬁned spaces
or other cramped or crowded conditions.
QQ=dli]Zl]ZZaX]V^gl^aaWZegdYjXZYWhen designing a new wheelchair, or selecting a pre-existing wheelchair design, it is important
to know where the wheelchair will be produced. In different locations, the technical skills,
available technology, materials and components available for production will vary. For thisreason, a wheelchair designed for one region may not be suitable in another region. However, thefundamental design might be quite similar.

DESIGN AND PRODUCTION

I 43'#'#'>cigdYjX^c\l]ZZaX]V^gYZh^\c
The following categories can be used to describe and evaluate wheelchair designs.
t Functional performance: how a wheelchair performs for different users in different environments.
The functional performance of a wheelchair is determined by its design and features.
t Seating and postural support: how a user’s body is supported by the wheelchair. This includes
comfort and pressure relief.
t Strength, durability and safety: considers the safety of the user, the resistance to breaking andthe durability of the wheelchair.
Design features, minimum guidelines and evaluation methods related to each category aredescribed in more detail in Sections 2.4, 2.5, and 2.6, respectively.

'#'#(I]ZYZh^\cegdXZhh
Wheelchair users are strongly encouraged to be involved in the design and selection process.
From experience, users are the most knowledgeable about their own physical, social and culturalneeds (3).
The steps in wheelchair design are:

Step 2: design/select wheelchair. Afterthe design brief is written, design ideas
are developed and prototypes are built
and tested in the workshop. The processof designing, prototyping and testing mayneed to be repeated several times until
the prototype meets the performancerequirements of the brief. A design brief canalso be helpful in selecting a wheelchair.

7HEELCHAIR DESIGN SELECTION
FOR LOCAL PRODUCTION  IMPORT.EEDS ASSESSMENT USERSTECHNOLOGY

5SER INPUT

Design briefs should be developed inconsultation with users and others familiar
with the needs of intended users, andaccording to available resources.

Fig. 2.2. Wheelchair design selection process%STABLISH CRITERIA FOR DESIGN$ESIGN  3ELECTWHEELCHAIR

0RODUCT TESTING PERFORMANCESTRENGTH AND DURBABILITY

5SER TRIALS

5SER INPUT

Step 1: design brief. This is a written
statement of the needs and criteria for thewheelchair. The criteria include:
t environmental constraints (physical,
cultural, social);
t local production resources, such as
materials and human resources;t performance requirements; andt target price.

0RODUCTION  0ROVISION OF
WHEELCHAIR,ONG TERM FOLLOW UP WITH USERS2

4 4 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

Step 3: product testing. When a prototype meets the performance criteria, it should be tested toensure it meets strength and durability requirements. If the wheelchair fails the tests, the design
may need to be changed.
Step 4: user trials. Once the prototype has met all the performance, strength, durability andsafety requirements, it should be tested by users who live in the environment the wheelchair isdesigned for. User trials allow for feedback from users, who are the most knowledgeable about theperformance of the device. (User trials are described in Section 2.7.)
Step 5: production and supply. If the user trials are successful, production and supply of thewheelchair may begin.
Step 6: long-term follow-up. At this point, long-term follow-up should be used to assess theperformance of the wheelchair over time (for example, over several months). The feedback thus
obtained should then be used to improve the design. (Long-term follow-up studies are describedin Section 2.7.)

AdXVaegdYjXi^dcgZhdjgXZh
As highlighted above in the design brief, an important element of the design process is to identify
local production and repair resources. A number of factors determine whether a particular designof wheelchair can be produced or repaired in a particular region, including:t the materials and spare parts available in that region;t the human resources and skilled technical labour available; andt the production equipment available.
Designers can use the above determinants to ensure the designed wheelchairs can be manufactured
or repaired in the region in question. These parameters also influence the type of production
facilities that can be used to manufacture the wheelchair.

Box 2.3. Using the design process for wheelchair selection
The design process can be an eﬀective tool for selecting wheelchairs for large-scale provision to a region or forindividual users. The steps in Fig. 2.2 can be followed to determine the wheelchair(s) that best meet the users’ needs.
Design brief. In cases where previously designed wheelchairs are being purchased (either locally or throughimportation), a design brief can be used to outline which features a wheelchair should have for the intended usergroups.
Testing. If reliable test results are available, they can be reviewed to ensure the wheelchair’s strength, durability andperformance. If such results are not available, product testing is recommended.
User trials and long-term follow-up. Even if the wheelchair has proved successful in other regions, it is strongly
recommended that it is tested by users living where it will actually be used. Long-term follow-up should be carried out
to ensure that the wheelchair continues to meet the needs of the users over time.

DESIGN AND PRODUCTION

I 45'#(L]ZZaX]V^gegdYjXi^dcVcYhjeean
Wheelchairs may be produced nationally or imported. To provide a range of wheelchairs, somecountries may choose to support both national production and importation. Each supply method
has an appropriate application (Table 2.1).

Table 2.1. Diﬀerent methods of wheelchair production and supply
National
production

Small-scale
Large-scale

Imported

Used
wheelchairs

Large-scale
production

Production of small numbers of wheelchairs using locally available materials andlow technology production methods to supply local wheelchair services.
Production of large numbers of wheelchairs to supply wheelchair services
nationally, regionally or locally.
Collection of used wheelchairs from high-income countries, refurbished andsupplied to less-resourced settings. Selection of the correct model is crucial in thisprocess. Often, such wheelchairs have been hospital-style wheelchairs designed for
temporary users.
Wheelchairs designed and produced for sale or donation in less-resourced settings,
sometimes assembled locally.

With many different needs within a region, a variety of supply methods may be suitable, the longterm goal being sustainable solution. It is recommended that all wheelchairs, irrespective of supply
method, meet or exceed national wheelchair standards and be repairable locally.
When determining whether to acquire wheelchairs via import or local production, decision-makers
are advised to balance a variety of factors. These include:t the needs of local wheelchair users;t the quality and variety of wheelchair models;t the long-term reliability of supply of wheelchairs and spare parts;
t the possibility of influencing the design, features, materials, etc.;t the purchase price;t the cost of repair and replacement;t the effect on local employment and wheelchair production;
t coordination of supply with an overall plan for wheelchair provision;t the amount and term of the funding available; andt policies and strategies, including long-term sustainability.

2

4 6 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S'#);jcXi^dcVaeZg[dgbVcXZ
Functional performance is how a wheelchair performs for different users in different environments.
The functional performance of a wheelchair is determined by its unique design and features. There
are many compromises to consider when designing or selecting for different uses.
This section provides information on the key features of a wheelchair that affects the main categories
of performance and how to evaluate them. It also outlines compromises that need to be consideredwhen choosing different design features.
To meet the functional performance needs of individual users, a range of wheelchair designs andsizes are needed.

'#)#&L]ZZaX]V^ghiVW^a^in
Wheelchair stability affects how safe the wheelchair is, and how well the user can carry out activities
in the wheelchair. Wheelchair tipping causes many injuries for users (4).
t Static stability relates to the stability of the wheelchair when it is not moving. This determines
whether the wheelchair will tip over (where some wheels lose contact with the ground) when
the user, for example, leans over to pick something up off of the ground or transfers into or outof his or her wheelchair.
t Dynamic stability relates to the stability of the wheelchair when moving. This determines whether
the user can ride over bumps or sloped surfaces without tipping.
The design features used to increase wheelchair stability have secondary effects on other functional
performance characteristics. For example, moving the front castor wheel forward increases stability
but reduces the manoeuvrability of the wheelchair in confined spaces. These relationships aredescribed below.
General stability is affected by the position of the combined centre of gravity of the user andthe wheelchair relative to its wheelbase. A way of increasing general stability and its associatedadvantages and disadvantages are shown in Table 2.2.

Table 2.2. Aim: to increase stability in all directions
Advantages
Disadvantages
By lowering the seat and thus the centre of gravity of the userQ
It may be easier for the user to reach objects on the ﬂoor. Q Being lower may make it harder to reach objects above.
Q
Q
The seat (and the user’s knees) will be more likely to ﬁt
The posture may be less comfortable and may increase
under desks and tables.
the pressure on the user’s seat (a cause of pressure
Q
Users will be more able to use their feet to assist withsores).
Q
The user’s pushing position may be worse and access topropulsion (if they are able).
the hand rims more diﬃcult.

DESIGN AND PRODUCTION

I 47

Apart from seat height, stability in each direction is sensitive to several design factors, as described
below.
Rearward stability (resistance to tipping backwards) is affected by the rear axle position in relation
to the user’s centre of gravity. Ways of increasing rearward stability and their associated advantages
and disadvantages are shown in Table 2.3.

Table 2.3. Aim: to increase rearward stability
Advantages
Disadvantages
By moving the rear wheel further behind the user’s centre of gravity
Q
Q
Some people, such as some double above-knee
Increased tendency to turn downhill on side slope.
Q
User will have poorer access to the hand rim and a
amputees, require increased rearward stability because
shortened push-stroke, making it more diﬃcult to pushtheir centre of gravity is further back.
the wheelchair and harder on the upper extremities.
Q
It will be more diﬃcult to perform a “wheelie” tonegotiate obstacles.
Q
Wheelchair is harder to manoeuvre in conﬁned spaces.
By using anti-tip devices to prevent a wheelchair tipping over backwards ( see Fig. 2.3)
Q
Q
Anti-tip devices can be useful for some users who are
Most anti-tip designs restrict the wheelchair’s ability tounstable or are learning to perform “wheelies” (whereby
travel over uneven surfaces (such as kerbs or dips).
the user raises the front castor wheels and balances on
the rear drive wheels).
Note: A bag, backpack or any weight hanging behind the wheelchair will move the centre of gravity back and make the wheelchair more likely to tip backwards.

Fig. 2.3. Anti-tip device2

4 8 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

Forward stability is affected by the size and position of the front castor wheel in relation to theuser’s centre of gravity. Ways of increasing forward stability and their associated advantages anddisadvantages are shown in Table 2.4.

Table 2.4. Aim: to increase forward stability
Advantages
Disadvantages
By moving the front castor wheel forward of the user’s centre of gravity
Q
Q
The wheelchair will resist tipping forward when theOverall wheelchair length is longer, making it harder tocastors are stopped suddenly by an object they cannot
manoeuvre in conﬁned spaces.
roll over.
Q
Less weight on the front wheels will reduce the rolling
resistance of the front wheels, allowing the wheelchair
to roll more easily.
By using larger front castor wheels
Q
Q
Front castor size signiﬁcantly aﬀects dynamic stability;
Larger front castor wheels need more room to swivel; thewith larger front wheels the wheelchair will be able towheelchair design will need to be much longer or wider
roll over larger obstacles without being stopped andto allow room for the user’s feet.
tipped forward.
Note: If the footrests are ahead of the front wheels, a weight placed on the footrests (a heavy child, for example) can tip the wheelchair forwards..

Sideways stability is affected by wheelchair width. The further out to the side of the wheelchair
the front and rear wheels touch the ground, the more the chair will resist tipping over sideways.
Ways of increasing sideways stability and their associated advantages and disadvantages are shownin Table 2.5.

Table 2.5. Aim: to increase sideways stability
Advantages

Disadvantages

By increasing the width of the wheelchair
Q
Q
Provides more stability.
A wide wheelchair is more diﬃcult to get throughQ
Comfortable seating.
narrow doorways.
Q
Q
Better for overweight people.
Not eﬃcient for pushing and hard on upper extremities
because the user has to reach out to push the hand rims.
By adding camber to the wheels (see Fig. 2.4)
Q
Camber brings the wheels closer to the user and more in Q A wide wheelchair is more diﬃcult to get throughline with the user’s forward push stroke, thus making it
narrow doorways.
Q
Camber increases the width of the wheelchair when it iseasier to push. This can be especially helpful for women,folded.
who usually have narrower shoulders but wider hips
than men.
Q
Traction is better when traversing slopes.

DESIGN AND PRODUCTION

I 49

Fig. 2.4. Wheelchair without camber (left) and with camber (right)

Users with advanced mobility skills and with good trunk control can partially compensate for someof the wheelchair’s instability if they can balance on the rear wheels (perform a “wheelie”) and ifthey can shift their weight forwards, backwards or to the side to prevent tipping.

'#)#'BVcdZjkgVW^a^in
Manoeuvrability has been divided into two categories: manoeuvrability around obstacles andmanoeuvrability over obstacles.
Manoeuvrability around obstacles determines the user’s ability to manoeuvre in an environment
with confined spaces, such as a toilet with a narrow door and very limited space.
t Moving through narrow passageways. The narrowest space through which a wheelchair canpass is determined by its width, measured from the outermost point on each side. The ability tomove through narrow passageways can be improved by making the wheelchair narrower. See
Table 2.6 for related design solutions and effects.
t Pulling up close to surfaces and objects. How close users can get to surfaces and objects theycannot roll under, such as toilets, low tables, counter tops, centre-post tables and bathtubs, isdetermined by how far the wheelchair extends both forwards and to the side of the seat. A user
can get closer to surfaces and objects if the wheelchair is shorter in height (see Table 2.6).

2

5 0 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

t Rolling under surfaces. The user’s ability to pull up to a table is determined by the height of

the user’s knees (the length of the user’s lower leg plus the minimum safe height of the footrest
above the ground). Some types of fixed armrest also prevent users from pulling up to tables andcounters.
t Turning around in confined spaces. The smallest area in which a wheelchair can turn aroundis determined by its maximum diagonal measurement (see Table 2.6).

Table 2.6. Aim: to improve the ability to turn round in conﬁned areas
Advantages
Disadvantages
By making the wheelchair shorter and narrower
Q
Q
Reduced weight.
A shorter and narrower wheelchair will be less stable.
Q
Easier to handle and transport.
Wheelchairs can only be as narrow as the user’s width
plus the wheels.
See Tables 2.4, 2.7 and 2.8 for related eﬀects.
By moving the rear wheel forward in relation to the user
Q
Improved access to hand rims. With a longer push stroke, Q Reduced rearward stability.
both forwards and backwards, the user is able to use
fewer strokes to turn in conﬁned spaces.
Q
With more of the user’s weight directly over the rearturning wheel, the wheelchair is more responsive toturning.
See Table 2.7 for related eﬀects.
If the wheelchair has easily removable footrests
Q
Increased ability to pull up close to surfaces and objects. Q Removable parts can be lost or broken.

Manoeuvrability over obstacles determines the user’s ability to negotiate obstacles such as soft
ground or raised obstacles. When negotiating obstacles, the user is at risk of tipping backwards
or forwards and falling out of the chair (a common cause of injury); thus it is also important toconsider stability when evaluating a wheelchair’s ability to manoeuvre over obstacles (see Tables
2.3 and 2.4).
t Manoeuvring over soft ground, such as mud, sand, grass, gravel and snow, depends on the areaof contact that the wheels have with the ground and the amount of weight on the wheel. Ways of
improving manoeuvrability over soft ground and their associated advantages and disadvantages
are shown in Table 2.7.

DESIGN AND PRODUCTION

I 51

Table 2.7. Aim: to improve manoeuvrability over soft ground
Advantages
Disadvantages
By increasing the width, diameter and softness of the castor wheel to increase the contact area,
thus helping to prevent the wheelchair from sinking into soft grounda
Q
Q
A wide wheel with a raised point on the centre of its
Increasing the contact area of the castor wheel with thetread can combine low rolling resistance on hard surfaces ground can make it more diﬃcult to turn, especially inwith good ﬂotation over soft ground.
tight, slow turns.
Q
Less weight on the front wheels will reduce the rolling
resistance of the front wheels, allowing the wheelchair
to roll more easily.
By increasing the width, diameter and softness of the rear wheel to increase the contact area,
thus helping to prevent the wheelchair from sinking into soft grounda
Q
Q
Larger-diameter rear wheels can make it easier to roll
Wider and softer rear wheels can make it more diﬃcult
over rough terrain.
to turn, especially in tight, slow turns.
Q
Q
In many less-resourced settings, 28-inch bicycle tyres
Larger-diameter rear wheels make the wheelchair moreare widely available; 26-inch tyres are somewhat lessdiﬃcult to transport.
common, and 24-inch tyres are more diﬃcult to ﬁnd.
By moving the front castor wheel(s) forward to reduce the weight on the smaller castor wheel(s)and make it less likely to sink into soft ground
Q
More of the user’s weight on the rear wheels will provide Q Overall wheelchair length is longer, making it harder tomore traction on the rear wheels to drive through soft
manoeuvre in conﬁned spaces.
ground.
See also Table 2.4 for related eﬀects.
By moving the rear wheels forward in relation to the user to reduce the weight on the front castor wheel(s)and make it less likely to sink into soft ground
Q
More of the user’s weight on the rear wheels will provide Q Reduced rearward stability.
more traction to the rear wheels to drive through soft
ground.
Q
Reduced tendency to turn downhill on side slope, which
requires less energy from the user to correct for downhill
turning.
Q
User has better access to the hand rim and a longer pushstroke, making it easier to push the wheelchair andbetter for the upper extremities.
Q
Easier to perform “wheelies” to negotiate obstacles.
Q
Wheelchair is easier to manoeuvre in conﬁned spaces.
By using rear wheels with knobs, such as those on mountain bike tyres,to increase traction on soft ground and keep wheels from slippingQ
Spikes or knobs on tyres cause additional ﬂexing of thetyre and thus higher rolling resistance.
Q
Mud will collect more on tyres with knobs than onsmoother tyres.
a

Substituting larger castor and/or rear wheels on a wheelchair not designed to take them can change important functional performance features,
including seat angle, castor barrel angle and seat height (user’s centre of gravity).

2

5 2 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

t Manoeuvring over raised obstacles, such as bumps, kerbs or rocks, depends on many factors.

The size of the castor wheel, the distance of the castor wheel from the user’s centre of gravity
and the springiness of the castor wheel all have a significant effect. Castor flutter is also a resultof hitting bumps at speed. Ways of improving manoeuvrability over raised obstacles and theirassociated advantages and disadvantages are shown in Table 2.8.

Table 2.8. Aim: to improve manoeuvrability over raised obstacles
Advantages
Disadvantages
By increasing the distance between the front castor wheel(s) and the user’s centre of gravity
See Table 2.4 for related eﬀects.
By increasing the diameter of the castor wheel
See Table 2.7 for related eﬀects.
By increasing the diameter of the rear wheel
See Table 2.7 for related eﬀects.
By increasing the amount of deflection/springiness of the castor wheel
Q
A softer wheel can make it more diﬃcult to turn,especially in tight, slow turns.
Q
A pneumatic castor wheel can be diﬃcult to repair or
replace.
Note: Although users with advanced mobility skills can compensate for a wheelchair’s lack of manoeuvrability over objects by moving their body
posture to balance the wheelchair, unseen obstacles can put the user’s safety at risk.

DESIGN AND PRODUCTION

I 53'#)#(Ejh]^c\Z[ÒX^ZcXn
Pushing efficiency is related to the amount of energy required for the user to push the wheelchairover a given distance. Lighter wheelchairs are normally easier to push, but there are many factors
and wheelchair features that affect how difficult or easy it is to push one’s wheelchair. Ways of
improving the pushing efficiency and their associated advantages and disadvantages are shownin Table 2.9.

Table 2.9. Aim: to improve pushing eﬃciency
Advantages
Disadvantages
By moving the rear wheels forward in relation to the user
See Table 2.7 for related eﬀects.
By optimizing seat width and putting the push rims in line with shoulders
Q
User will not have to reach out for hand rims.
By putting camber in the rear wheels
Q
Brings the top of the hand rims closer to the body andmore in line with the user’s natural push stroke.
See also Table 2.5 for related eﬀects.
With an aligned wheelchair; wheelchair is in good condition and working order
Note: A wheelchair with a broken or misaligned component (e.g. untrue wheels, distorted frame, broken bearings
causing friction, unparallel wheels or poorly inﬂated pneumatic tyres) resists the user’s forward motion, thereby wasting
much of the user’s pushing energy.
For use on smooth ground, use harder tyres
Q
Q
Harder tyres (which deform less) have lower rolling
Harder/solid tyres provide little shock absorption.
resistance on smooth ground than softer tyres, all other Q Solid tyres are diﬃcult to repair or replace (unless a
supply of replacement parts is available).
factors being equal.
Q
Solid tyres can never fail the user by being punctured.
For use on imperfect surfaces (such as outdoors), use tyres that return energy and “spring back”(such as pneumatic tyres)
Q
Q
Tyres that return energy have lower rolling resistance
Spikes or knobs, such as those on mountain bike tyres,than those that dissipate energy (i.e. they deform
cause additional ﬂexing of the tyre and thus higher
but return to shape slowly, such as solid foam tyres orrolling resistance.
Q
Pneumatic bicycle tyres can be punctured.
inserts).
Q
Pneumatic bicycle tyres are relatively easy to repair withthe right facilities.
For use on imperfect surfaces, use larger-diameter wheels that have lower rolling resistancethan smaller wheels of similar construction2

5 4 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S'#)#)Di]Zg[jcXi^dcVaeZg[dgbVcXZX]VgVXiZg^hi^Xh
Ability to transfer into and out of the wheelchair depends on the type of transferral that is easiest
for the user and whether the wheelchair’s structure impedes transferral. Ways of making transfer
easier and their associated advantages and disadvantages are shown in Table 2.10.

Table 2.10. Aim: to make transferral easier
Advantages

Disadvantages

By having removable or folding armrests
There is more room for the user to be in an easy position Q Removable components can get lost.
Q
Mounting locations can become bent or damaged,
for transferring sideways into or out of the wheelchair.
making them diﬃcult to put on and take oﬀ.
Q
Locking mechanisms can fail, creating a dangerous
situation when an assistant tries to lift the wheelchairand user up stairs while holding the armrests.
By having fixed armrests that do not extend to the front of the seat
Q
Q
Greater comfort.
Creates obstacles to easy transferral.
Q
It helps to transfer upwards into a taller vehicle.
Q
Ability to raise the body and take the weight frompressure-sensitive areas during prolonged sitting.
By having detachable armrests
Q
Q
Easy to transfer.
Armrests can be easily lost or damaged.
Note: For users who transfer by pivoting their bottom about their knees (side transfer), there must be suﬃcient space atthe end of the seat surface to be able to move their body past the armrest.
By having removable footrests
Q
Removable footrests can allow a user to pull up closer to Q Removable components can get lost.
Q
Locking mechanisms can fail, creating a dangerous
surfaces to which the user wishes to transfer.
Q
For standing transfers, removable or ﬂip-up footrests are
situation when an assistant tries to lift the wheelchairneeded to get out of the way of the user’s feet.
and user up stairs while holding the footrests.
See also Table 2.6 for related eﬀects.
By having, for standing transfers, a seat with little to no backward tilt (reclined seat angle)
Q
Q
Dependent on user’s abilities in transferring.
Insuﬃcient backward tilt of the seat (seat angle) canlead to poor posture and to pressure sores in users
without full sensation in their buttocks.
Q
Note: Too much tilt will cause high localized pressure on
the buttocks.
Q
Less backward tilt shifts the user’s centre of gravity
forward, which makes the wheelchair less stable in theforward direction.
Q
During an impact, if the wheelchair does not tip forward,
the seat angle and surface material (of seat and seatcushion) will aﬀect whether or not the user slides out of
the seat.
Q

Note: Transferring in and out of a three-wheeled wheelchair requires a diﬀerent technique to avoid the central frame tube at the front. In a threewheeled wheelchair, users can get closer to objects by approaching them at an angle.

DESIGN AND PRODUCTION

I 55

Transporting the wheelchair. For long-distance travel by, for example, bus, taxi or train, it isimportant to take account of the design and size of the wheelchair and the materials used in its
construction. Weight is a crucial factor in transporting a wheelchair, and weight is determined by
the types of component (wheels/frames) used and by the construction materials (e.g. steel, steel/aluminium alloy or other metal). Reducing weight has a direct effect on durability and cost. Designand size are equally important, foldable and smaller wheelchairs being easier to carry. Ways ofmaking it easier to transport a wheelchair and their associated advantages and disadvantages areshown in Table 2.11.

Table 2.11. Aim: to make it easier to transport the wheelchair
Advantages

Disadvantages

By reducing the weight of the wheelchair
Q
Q
Greater convenient for the user and family members/
Reduced durability.
caregivers.
Q
Greater mobility and productivity.
By using folding mechanisms built into the frame (i.e. cross-folding frame, folding backrest)
to make the wheelchair more compact for transportingQ
Q
Makes the wheelchair easier to carry and transport.
Makes the wheelchair comparatively heavier.
By having components (i.e. wheels, footrests, armrests) removable to help reduce
the overall weight and size for lifting, transport and storage
Q
Q
Reduced weight and volume.
Removable parts can get lost, bent or broken.
Q
Q
Makes the wheelchair easier to carry and transport.
Standard push-button quick-release axles are notavailable everywhere and are expensive compared toﬁxed axles.
Q
Standard push-button quick-release axles have a shorter
life where conditions of use are rough, whereby sand,dust and moisture can cause the locking mechanism toseize. This can allow the axle to slip out of the axle socket
and the wheel to fall oﬀ the wheelchair.
Other factors
Q
Wheel camber increases the folded width of thewheelchair.
Q
More stable wheelchairs with long frames are morediﬃcult to transport.
Q
Spiked or knobbly “mountain bike” style tyres tend tocollect more mud and soil than smooth tyres, which may
reduce cooperation from taxi drivers and bus passengers.

2

5 6 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

Reliability. A wheelchair’s reliability is determined by its durability and the length of its usefullife. In the case of failure, the frequency and difficulty of repair also determines the reliability of aparticular model of wheelchair. Ways of improving the reliability of a wheelchair include:t better materials and technologies at an affordable cost;t fewer removable parts;
t non-folding design where folding is not a necessity;t use of materials that can be repaired or replaced locally;t regular servicing, repair and maintenance; andt knowledge by the user of the product and its use, care and maintenance.

'#)#*:kVajVi^c\[jcXi^dcVaeZg[dgbVcXZ
It is recommended that a wheelchair be evaluated based on the functional performance measuresand that the results be available to the users and purchasers. The functional performance areas inwhich a wheelchair should be evaluated or reported on are:t static stabilityt dynamic stability
t rolling resistancet ability to repair/availability of componentst overall dimensions, mass and turning space.
Static stability and overall dimensions, mass and turning space tests and reporting techniques arecovered in ISO standards 7176-1, 7176-5 and 7176-7.

'#*HZVi^c\VcYedhijgVahjeedgiZaZbZcih
All wheelchairs provide seating and postural support as well as mobility. Good postural support isimportant for everyone, especially for people who have an unstable spine or are likely to develop
secondary deformities. The significance of good seating and postural support can mean the
difference between the user being active and an independent member of society and the user
being completely dependent and at risk of serious injury or even death.
All body contact surfaces provide seating and postural support. Together, these parts of thewheelchair help the user to maintain a comfortable and functional posture and to provide pressure
relief. This is very important for users who have problems with skin sensation. The common areas
where likely problems might occur are shown in Fig. 2.5 and 2.6.

DESIGN AND PRODUCTION

Fig. 2.5. Common pressure sensitive areas (side view)Fig. 2.6. Common pressure sensitive areas (back view)

The recommendations set out in Box 2.4 can be used as a guide in the design and selection of basic
wheelchairs. They do not cover wheelchairs that provide a higher level of adjustability or custom
adaptations for users who require more complex postural support.
Box 2.4. General seating and postural support guidelines
A wheelchair and cushion should meet the seating and postural support requirements of the user(s). This includes thesize of the wheelchair, the type of cushion, and the adjustability and ergonomic factors of the wheelchair.
Q
All wheelchairs should be provided with a cushion that is appropriate to manage the user’s risk of developing pressure
sores.
Q
A wheelchair should be evaluated based on the seating and postural support measures, and the results should beavailable to the users and purchasers.
Q
Cushions should be evaluated and rated based on their ability to provide comfort, pressure relief and postural
support, and the results should be available to the users and purchasers.
Q

I 57

2

5 8 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S'#*#&HZViWVhZh
The two most common types of seat base are sling seats (Fig. 2.7.) and solid seats (Fig. 2.8.). Slingseats (also known as slung seats) are made of a flexible material such as canvas or vinyl. Solid seats
are not flexible and are often made of wood, metal plate or plastic. The list set out in Box 2.5 provides
recommendations for each seat type.
Box 2.5. Guidelines for seat bases
Wheelchair seats should have a continuous surface with no breaks that might cut or pinch the user’s skin.
The angle of the seat, in relation to the horizontal, should be between 0 and 12 degrees (with the front portion of theseat higher than the rear portion of the seat).
Q
The seat must be level from side to side.
Q
A range of seat sizes should be available to ﬁt a range of body sizes.
Q
Sling seats should be designed with materials that do not stretch over time from the weight of the user.
Q
Sling seats and solid seats should be used with cushions designed or modiﬁed for use on a sling seat and solid seat,
respectively (Fig. 2.9.).
Q
Q

Fig. 2.7. Sling or slung seatFig. 2.8. Solid seatFig. 2.9. Seat with detachable cushion

Failure of the wheelchair seat and the cushion is a common problem. Sling seats made of poor
quality or inappropriate materials can quickly stretch, sag and tear. Wheelchair cushions are notdesigned to work on such seats made of poor quality or inappropriate materials. This means thatthe user ends up sitting on an unstable seat without pressure relief. The result can be that theuser will develop pressure sores or stop using the wheelchair owing to discomfort. Some design
solutions include:t tension-adjustable sling seats made with straps and stretch-resistant fabric; andt pressure-relief cushions for wheelchairs with sling seats provided with a contoured bottom
surface to accommodate the curve of the sling.
Many cushions can easily be modified for use on a sling seat by cutting off the lower, outer edge
from front to back on each side to accommodate the seat rail and the curve of the sling.

DESIGN AND PRODUCTION

I 59'#*#'8jh]^dch
An inadequate pressure-relief cushion is the one component of a wheelchair that is most likely tocause pressure sores, serious injury or premature death. Wheelchair cushions are used for threereasons: comfort, pressure relief and postural support. For many users, a cushion that provides
some comfort will help them to use the wheelchair for a longer time. Users with limited or noskin sensation are always at risk of developing pressure sores when using a wheelchair without aproper cushion. These users must use a pressure relief cushion to help reduce this risk as shown in
Fig. 2.10 and Fig.2.11.

Fig. 2.10. Wheelchair cushion

Fig. 2.11. Wheelchair cushion

2
Many users require some adaptations or modifications to their cushion to help provide additional
postural support or pressure relief. Wheelchair manufacturers need to either keep a good stock ofdifferent types and sizes of cushion or have the capacity to produce and modify a cushion as andwhen needed. Recommendations for cushions are given in Box 2.6.
Box 2.6. Guidelines for cushions
The cushion should be removable from the wheelchair.
The cushion should be easy to clean using basic materials such as soap and water.
Q
The cushion should be an appropriate size to ﬁt on the seat base.
Q
Correct cushion use and the way in which it should be placed on the wheelchair seat (which side is up, and which isthe front of the seat) should be clearly indicated.
Q
Information on how the cushion should be used and maintained should be available.
Q
Q

Pressure relief cushions
Q
A pressure relief cushion should reduce pressures at the high-risk areas for pressure sore development (commonly at
ischial tuberosities and sacrum).
Q
A pressure relief cushion should minimize the build-up of moisture between the cushion and the user’s skin.
Q
Information should be available on how to use the cushion, how to maintain it, the expected life of the cushion, whento replace the cushion or parts of it, and any particular risks when using the cushion.
Q
The cushion and cushion cover material should not cause high pressures, thereby reducing the eﬀectiveness of thecushion in distributing pressure over the seat surface.
Q
Pressure relief cushions should maintain their pressure relief properties in the climates where the cushion is expected
to be used.

6 0 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S'#*#(7VX`gZhih
The backrest provides users the necessary postural support. It needs to be of different heights but
usually available in two sizes as shown in Fig. 2.12 and Fig. 2.13.
Some users require more support from a backrest than others. For some users, a high backrest can
reduce their ability to propel themselves effectively. Backrests may be sling or solid types with foamcushioning and upholstery. Recommendations for backrests are given in Box 2.7.

Fig. 2.12. Low backrest

Fig. 2.13. High backrestBox 2.7. Guidelines for backrests
The angle between the seat andthe backrest (seat to back angle)
should be between 80 and 100
degrees.
Q Diﬀerent backrest heights
should be available.
Q The backrest should support thenormal curvature of the spine.
The middle of the back shouldbe able to rest further back thanthe back of the pelvis.
Q'#*#);ddigZhih
The footrest provides users with support for their feet and legs. Footrests must be individually
adjusted for each user. Correctly adjusted, the footplate reduces pressure on the user’s seat andputs the user in a healthy sitting posture. Footrests may also include a calf strap to keep the foot on
the footplate. Sufficient ground clearance needs to be maintained to prevent the footrest hitting
obstacles or catching and tipping the wheelchair on uneven ground. The height of the footrest
should be adjustable. Footrests need to be long or wide enough to support the foot but, at thesame time, should not create difficulty while folding or moving around. For other performancefactors related to the footrest see Table 2.10.

DESIGN AND PRODUCTION

I 61'#*#*6gbgZhih
Users should use armrests only for temporary postural support. If needed, other postural support
options should be used to keep the user’s arms free for activities such as propelling. Armrests
assist in transferring into and out of the wheelchair, for example by pushing up on the armrest(Fig. 2.14).

Fig. 2.14. Low proﬁle armrest

2
Many users find it easier to transfer into and out of their wheelchair if the armrests are “low-profile”(closely following the profile of the rear wheel) or removable (Fig. 2.15.). In other words, armrests
should be removable, folding or low-profile for easy transferral in and out of the wheelchair. For
other performance factors related to the armrest see Table 2.10.

Fig. 2.15. Easy to transfer

6 2 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S'#*#+GZVgl]ZZah
The rear wheel should be in a position that allows the user to have the best push stroke as possible
and keeps the user safely balanced according to his or her skill level and ability. The position of therear wheel should allow the user to have a good push stroke and provide the necessary stability.

'#*#,:kVajVi^c\hZVi^c\VcYedhijgVahjeedgiZaZbZcih
It is recommended that wheelchairs and cushions be evaluated based on the seating and postural
support performance measures, and the results be available to the users and purchasers. The areasin which a wheelchair and cushion should be evaluated or reported on are:t seating dimensions and adjustabilityt cushion type and characteristics.
Seating dimensions and cushion characteristics tests and reporting techniques are covered in ISO
standards 7176-7 and 16840-2 (5).

'#+HigZc\i]!YjgVW^a^inVcYhV[Zin
The goal of this section is to help define what makes a safe and reliable wheelchair, and how toevaluate and report these attributes to stakeholders (see Box 2.8). When a wheelchair fails, the user
is not only at risk of injury but may not be able to go anywhere or do anything until the wheelchairis repaired or replaced.
Apart from ensuring that the wheelchair is safe and effective, evaluating strength and durability is
a way of gathering important information that can be useful for all stakeholders – users, designers,
providers, manufacturers and funding agencies. Keeping accurate records of the results of strengthand durability tests will help wheelchair designs evolve so that their quality and effectiveness
continually improve.
Box 2.8. Strength, durability and safety guidelines
All wheelchairs should meet the strength, durability and safety requirements of user(s) in their own environment(s).
It is recommended that each country develop its own wheelchair standards to ensure a reasonable quality, forinstance by using the ISO 7176 series of standards as a basis. When developing national standards, it is important
to consider the weights and sizes of the users, typical use, available testing equipment and available wheelchair
technology. The standards should be available to manufacturers, purchasers and users, and be reviewed from time totime.
Q
All wheelchairs should be evaluated based on the strength, durability and safety requirements set by the country, andthe results should be available to users and purchasers.
Q
Q

DESIGN AND PRODUCTION

I 63'#+#&GZfj^gZbZcih
A wheelchair should be strong and durable enough to withstand the wear and tear placed on it by
the user and to keep the user safe. Wear and tear consists of:t static forcest impactst fatigue stresses from use over time.
Simple testing device can be developed to ensure strength and durability, as shown in Fig. 2.16.
The flammability of the wheelchair, the effectiveness of the brakes and the safety of the surfaces
on the wheelchair also affect the safety of the user.

Fig. 2.16. Testing device2

6 4 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G STable 2.12 provides a list of ways in which wheelchairs are used and the related strength anddurability requirements for each component.

Table 2.12. Wheelchair uses and required durability and strength requirements
Part
Footrest

Brake
ArmrestPush handles
Frame
Backrest and seat
Rear wheel and axle

Castor assembly
GeneralMiscellaneous

Fatigue test

Need for strength, durability and safety
Footrest should fold with a reasonable amount of force.
Footrest should not break or bend when used to lift user and wheelchair.
Footrest should not break or bend when additional passengers or packages are loaded.
Footrest should not break or bend when hitting an object such as a wall or curb.
Brakes should stop a wheelchair from sliding when on an incline.
Brakes should not suddenly release while in use.
Armrest should be removable with a reasonable amount of force.
Armrest should not break or bend under the user’s body weight.
Armrest should not break or bend when used to lift user and wheelchair.
Push handles should not break or bend when used to lift user and wheelchair.
Handgrip should not slide oﬀ of push handle when user is being assisted up stairs or curb.
Frame should not break or bend when used on uneven terrain.
Backrest, seat and frame should not break or bend during transferrals or while riding on
uneven terrain.
Frame, wheels or axles should not break or bend when user goes over a normal kerb.
Wheels, axles or wheel-mounting hardware should not fail when user drops oﬀ kerb at angle.
Axles or wheel-mounting hardware should not break or bend when under typical forces.
Castor should not fail when the castor wheel hits an object (e.g. a curb).
Surfaces should not have sharp edges, sharp points or pinch points.
Wheelchair should not be ﬂammable, i.e. easily combustible materials should not be used.
Wheelchairs should be equipped with front and rear reﬂecting stickers or signs for increasedroad safety.
Tipping levers should not break when assistant uses levers to tip user back.
Hand rim should not break or bend when it hits an object.
Wheelchair should not break when it falls or is dropped by handler loading or unloading itfrom bus or car.
Wheelchair should not break in normal use.

DESIGN AND PRODUCTION

I 65'#+#':kVajVi^c\higZc\i]!YjgVW^a^inVcYhV[Zin
It is recommended that a wheelchair be evaluated based on the strength, durability and safety
requirements, and the results be available to the users and purchasers. Static strength, impact
resistance, durability and brake effectiveness tests and reporting techniques are covered in ISO
standards 7176-8, 7176-3 and 7176-16 (6).
National testing. It is recommended that testing according to national wheelchair standards bemade easily accessible to all manufacturers and providers. One method for making testing accessible
is to use testing methods that are simple and inexpensive.
Fatigue tests. Fatigue testing is critical for ensuring the reliability and safety of a wheelchair. Where
fatigue testing is not possible, it is especially important to carry out well-monitored user trials andlong-term follow-up to evaluate safety, reliability and durability.
Even those who do perform fatigue testing need to be aware that the testing equipment andprescribed cycles of the standards do not necessarily reflect the actual loads the wheelchair will
endure over its lifetime. Monitoring the use of the wheelchair in the field will help to determine
the durability and performance of the wheelchair over time.
Environmental testing. Workshop testing does not subject wheelchairs to environmental conditions
that they typically endure. Many wheelchairs fail as a consequence of dirty or worn bearings, rusty
bolts or frames, etc. Therefore, long-term follow-up of users is of great importance.

'#,JhZgig^VahVcY[daadl"jeUser trials. User trials are performed after workshop tests to provide feedback about the durability,
effectiveness and functional performance of a wheelchair in the context and environment in which
it will be used. User trials involve the selection of users who agree to use pre-production or predistribution wheelchairs over a given period of time. The users provide feedback at set intervals
during the trial, answering specific questions about the wheelchair’s performance. Focus groups
can also be used to ensure as much feedback is gained as possible.
If user trials reveal that failures are likely to occur, then design changes should be made or a different
wheelchair should be found, and testing should begin again. In the case of production, if significant
design changes are called for, strength and durability testing should be performed again, followedby more user trials. If only minor changes are called for, then it may be appropriate to skip thestrength and durability testing and perform the user trials again.

2

6 6 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G SLong-term follow-up. After workshop and user trial testing has proven the wheelchair design is safeand effective, the wheelchair will be put into production and then sent to wheelchair services forprovision. A sample of wheelchairs should be followed over time. This could be done, for instance,by contacting selected users six months, one year and three years after they received the wheelchair
to determine the typical failures and maintenance requirements and their general opinion on thefunctional performance of the wheelchair.
Recommendations for user trials and long-term follow-up are given in Box 2.9.

Box 2.9. Recommendations for user trials and follow-up
Wheelchairs should be tested by users in the context and environment in which they will be used, before they aresupplied to services or users (before production or before large-scale purchase) (7,8).
Q
Long-term follow-up studies should be used to ensure the wheelchair is safe and eﬀective over longer periods of use (9).
Q

HjbbVgnt Governments are recommended to develop and adopt national wheelchair standards to ensurea reasonable quality of wheelchairs, for instance by using the ISO 7176 series of wheelchairstandards as a basis.
t It is recommended that the national wheelchair standards are applicable to all wheelchairs
supplied in a country, whether produced within the country or imported.
t General design considerations include user health and safety, strength and durability, suitability
for use and production methods.
t Wheelchair designs should be evaluated in three areas: functional performance; seating andpostural support; and strength, durability and safety.
t Results of the evaluation and testing of wheelchairs must be available to users and purchasers.
t A variety of factors need to be considered when determining whether wheelchairs should beacquired through national production or importation.
t Wheelchairs and spare parts need to be available, accessible and affordable.

DESIGN AND PRODUCTION

I 67

GZ[ZgZcXZh
1.

2.
3.

4.
5.

6.

7.
8.
9.

ISO 7176-24:2004. Wheelchairs – Part 24: Requirements and test methods for user-operated stair-climbing devices. Geneva,
International Organization for Standardization, 2004 (http://www.iso.org/iso/iso_catalogue/catalogue_tc/catalogue_detail.
htm?csnumber=31276, accessed 9 March 2008).
Chan SC, Chan AP. User satisfaction, community participation and quality of life among Chinese wheelchair users with spinal
cord injury: a preliminary study. Occupational Therapy International, 2007, 14:123–143.
Krizack, M. The importance of user choice for cost-effective wheelchair provision in low-income countries. In: Proceedings,
12th World Congress of the International Society for Prosthetics and Orthotics, Vancouver, 29 July – 3 August 2007. Copenhagen,International Society for Prosthetics and Orthotics, 2007.
Kirby RL, Ackroyd-Stolarz SA. Wheelchair safety – adverse reports to the United States Food and Drug Administration.
American Journal of Physical Medicine & Rehabilitation, 1995, 74:308–312.
ISO 7176-7:1998. Wheelchairs – Part 7: Measurement of seating and wheel dimensions. Geneva, International Organizationfor Standardization, 1998 (http://www.iso.org/iso/iso_catalogue/catalogue_tc/catalogue_detail.htm?csnumber=13783,
accessed 9 March 2008).
ISO 7176-8:1998. Wheelchairs – Part 8: Requirements and test methods for static, impact and fatigue strengths. Geneva,
International Organization for Standardization, 1998 (http://www.iso.org/iso/iso_catalogue/catalogue_tc/catalogue_detail.
htm?csnumber=13784, accessed 9 March 2008).
Armstrong W et al. Evaluation of CIR-Whirlwind Wheelchair and service provision in Afghanistan. Disability and Rehabilitation,
2007, 29:935–948.
Pearlman J et al. Lower-limb prostheses and wheelchairs in low-income countries: an overview. IEEE Engineering in Medicine
and Biology Magazine, 2008 (in press).
Reisinger KD et al. Whirlwind Wheelchair in Afghanistan: nine-month follow-up. In: Proceedings, 12th World Congress of theInternational Society for Prosthetics and Orthotics, Vancouver, 29 July – 3 August 2007. Copenhagen, International Society for
Prosthetics and Orthotics, 2007.

2



3

H:GK>8:9:A>K:GN… to ensure that users receive appropriate wheelchairs.

The service delivery guidelines:t suggest strategies for introducing wheelchair
service delivery;t describe basic wheelchair service delivery;t provide practice guidelines;t suggest roles for the personnel involved; andt make recommendations on monitoring andevaluation.

I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

Box 3.1.

Wheelchairs
ee c a s changing
c a g g lives
es …
Testimonial from a user in Romania
Ciprian is 25 years old and lives in
Sfantu Gheorghe, Romania. Three
years ago he became paraplegic
after falling from a roof whileat work and lost any hope that
he would ever have a normal
and active life again. Some timeafter the accident, however,
he heard about a local
nongovernmental organizationthat provided support for users.
Through the wheelchair service
run by the organization, Ciprianreceived an active-style manual
wheelchair that was fitted for him.
He was also invited to participate
in a peer group training camp.
Ciprian says: “Once I got there I realized that I could have an independent life. Throughthe peer group training, I learnt to use my wheelchair very well. I also had the chance totalk with other users involved in the programme. At the end of the camp, I was asked if I
would like to become a peer group trainer. Of course, I was very happy about this chancethat had just been offered to me. In January 2006, I started my work as an instructor.
Through my wheelchair, and peer training, I have recovered the independence I thought
I had lost because of the injury. In addition to my peer group training work, I take part invarious competitions and sports activities for people in wheelchairs. Working with people
with disabilities makes me feel that I am useful again and that I finally have a normal life
after I had had such a hard time overcoming the health problems brought about by the
injury.”ttestimonialtSERVICE DELIVERY

I 71(#&>cigdYjXi^dc
EjgedhZVcYdjiejih
The purpose of the service delivery guidelines is to improve the way in which users receive
wheelchairs and to ensure that the wheelchairs are appropriate.
Implementation of the recommendations in this chapter will contribute to:t a greater number of wheelchair services;t better knowledge of wheelchair service delivery among health care and social service workers;
t better service quality delivered by existing wheelchair services;t a greater number of appropriate wheelchairs provided to users;
t a greater number of users able to make informed decisions about the most appropriate wheelchairfor them;t a greater number of users and caregivers receiving training in the use and maintenance of
wheelchairs, and on how to stay healthy in a wheelchair;t links between users and producers, leading to producers obtaining feedback on the wheelchairs
they produce; andt coordinated efforts in the planning, implementation and support of wheelchair service delivery
among stakeholders.

L]Vi^hVl]ZZaX]V^ghZgk^XZ4In the rehabilitation of a person with a walking limitation, the provision of an appropriate wheelchairis critical. It is important that the wheelchair fits correctly and meets the user’s physical, functionaland environmental needs as much as possible (1). This requires an approach that responds toindividual needs. An effective way of meeting the individual needs of users is to promote theprovision of wheelchairs through wheelchair services.
Wheelchair services provide the framework for assessing individual user needs, assist in selecting
an appropriate wheelchair, train users and caregivers, and provide ongoing support and referral
to other services where appropriate.
t Assessment. This is a process of mutual consultation between a person with disability and service

personnel, the aim being to assist the user to select the right product. The outcome is often aprescription detailing the features of the wheelchair most suitable for the person in question.
t Provision. Following assessment, wheelchair services provide an appropriate wheelchair. This
includes ordering, assembly if needed, and fitting of equipment.
t Training. In order for users to gain maximum benefit from their wheelchair, the services
provide them and their caregivers training in how to maintain the wheelchair and how to use it
effectively.
t Support. For all users, the services offer continuing clinical and technical support. This includes
providing basic health care advice, especially on how to avoid pressure sores or any further
deformities or complications, and follow-up and repair services.
t Referral. Where appropriate, the services will refer users to other services that may be of benefit
to them, such as physiotherapy, peer group training and vocational training.

3

7 2 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

In addition to the key functions listed above, providers of wheelchair services will play a role in:t awareness: disseminating basic information about the needs for and benefits of using awheelchair (this can also be done by personnel involved in community-based rehabilitation,
health and education programmes as well as by disabled people’s organizations); and convincing
policy-makers about the benefits of investing in wheelchair provision rather than leaving people
with disabilities to survive on charity;t identification: using a screening tool to identify those who can benefit from available services;t awareness of referral networks and suppliers: promoting the role of wheelchair services,
including participation in activities aimed at educating referral networks and raising theawareness of suppliers and funding agencies regarding the role and importance of wheelchair
services;t sustainability: developing sustainable financial solutions for the continuing provision of mobility
equipment through wheelchair services;t training: providing or supporting the training of wheelchair service personnel;
t standards: raising wheelchair standards within the country or region through being aware ofcurrent wheelchair availability and advocating for improvements in and a greater variety ofwheelchair products; andt accessibility: supporting or facilitating the adaptation of homes (including toilets, furniture andfittings) and public buildings and places, and lobbying for a barrier-free environment.

HigViZ\^Zh
Wheelchair service delivery requires careful planning and management of resources. There follow
a number of strategies that can be employed to initiate or further develop wheelchair services.

Egdk^Y^c\l]ZZaX]V^ghid\Zi]Zgl^i]hZgk^XZhThere are different methods of wheelchair supply to meet the range of contexts in which users
live (see Sections 1.7 and 2.3). Whatever the method or structure chosen, it is important to deliver
essential wheelchair services (2,3).

Ji^a^o^c\Zm^hi^c\eZghdccZa
It is not necessary to create a new profession to provide wheelchair services. With additional
training, many health and rehabilitation personnel would be able to take on the duties required forbasic wheelchair service delivery. For example, community health care workers, community-based
rehabilitation workers, nurses, physiotherapists, occupational therapists, orthotists and prosthetists
could be trained to fulfil the clinical role in wheelchair services. Likewise, with additional training,skilled craftspeople, mechanics and orthotic and prosthetic technicians could fulfil the technicalrole.

BZZi^c\i]ZcZZYhd[jhZghViXdbbjc^inaZkZa
Some aspects of wheelchair provision can be carried out in the community, through a network ofcommunity-based organizations (for example rehabilitation and health programmes) supported
by a local wheelchair service centre. The personnel of the community-based programmes could
be trained by wheelchair service personnel in basic service delivery. This system of service delivery
would best suit users who require a basic wheelchair, without modifications, postural support orpressure management care.

SERVICE DELIVERY

I 73

Users with more complex needs are likely to require the skills of personnel with greater training
than can be provided to all community-level personnel. This need can be addressed by outreachservices coordinated by the wheelchair service centre. If outreach services are not developed,
these users would need to travel to the wheelchair service centre. However, once provided with
an appropriate wheelchair, they may be supported by community-based personnel.
A wheelchair service can make use of the skills, technologies and capacities of local industries. For
example, bicycle repair shops can also repair wheelchairs, and tubular furniture makers have thebasic skills and knowledge to build wheelchairs.
Table 3.1 provides a summary of a “two-tier” wheelchair service approach. This shows a possiblemodel linking a wheelchair service centre with a number of community-based wheelchair services.
To provide adequate support to the community-based centres, it may be necessary to first develop
the wheelchair service centre. Alternatively, a collaborative effort between existing communitybased centres could work towards the development of the wheelchair service centre. In either
case, the development process should be based on a needs assessment and other aspects of thelocal context.

Table 3.1. Description of a two-tier wheelchair service approach
Wheelchair
service
centreCommunitybased
wheelchair
services

Characteristics
Centre-based.
Facilities (possibly shared with existing health or
rehabilitation services): clinical and user training
facilities; workshop facilities.
Staff: dedicated wheelchair service centre
personnel trained to meet the needs of all users.

Centre-based, with some wheelchair service
delivery carried out entirely in the community.
Facilities (shared with other community healthand rehabilitation programmes): access to clinic,
user training facilities, basic workshop facilities.
Staff: community health and rehabilitation
workers trained in basic wheelchair service
delivery, supervised and supported by wheelchair
service centre personnel.

Key functions
Wheelchair service delivery for all users.
Community outreach; linking with communitybased wheelchair services and referral networks.
Training, support and supervision of communitybased wheelchair services and personnel.
Education of referral sources.
Linking with education, employment and other key
development sectors.
Wheelchair service delivery for users requiring
basic wheelchairs without custom modifications or
postural support components.
Identification of users with complex needs, andreferral to wheelchair service centre.
Where appropriate, support of users with more
complex needs for follow-up, maintenance andrepair in the community.
Support of accessibility, including adaptation ofuser’s environment such as wider doors and ramps.

3

7 4 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S>ciZ\gVi^c\l]ZZaX]V^ghZgk^XZh^cidZm^hi^c\]ZVai]dggZ]VW^a^iVi^dchZgk^XZh
A wheelchair service centre or department can be established within existing rehabilitation services.
Such services are already likely to have users accessing the service for health or rehabilitation needs.
They would therefore already have much of the infrastructure required. Examples of rehabilitation
services well suited to the integration of a wheelchair service include prosthetics and orthotics
services and spinal injury centres.
Wheelchair services could play a dual role, providing wheelchairs directly to users and supporting
basic services in the community through partnerships with community-level programmes andorganizations.

HiV`Z]daYZghVcYgZhdjgXZhStakeholders directly involved in the planning, implementation and participation in service delivery
include:t users and their families or caregivers;
t government authorities, including ministries responsible for health, social welfare and educationand other relevant departments and local authorities;
t existing health and rehabilitation services (including referral networks) managed by governmental,
private, nongovernmental, international nongovernmental or disabled people’s organizations;t supporting organizations providing technical input or funding;t rehabilitation personnel and their organizations; andt wheelchair service personnel.
The resources required to implement the recommendations include:t a reliable supply of wheelchairs that meet agreed standards;
t access to different types and sizes of wheelchair to meet the varied needs of individual users;t personnel with training in wheelchair service delivery;t facilities (which may be shared with existing rehabilitation or health services):t DMJOJDBMGBDJMJUJFTQSPWJEJOHTVóDJFOUTQBDFGPSBTTFTTNFOU CBTJDVTFSUSBJOJOHBOETUPSBHFPG
wheelchairs, andt XPSLTIPQ GBDJMJUJFT  QBSUJDVMBSMZ XIFSF NPEJöDBUJPOT UP XIFFMDIBJST BSF PòFSFE PS QPTUVSBM
support is provided;t materials for wheelchair modifications and custom components; andt funding to support wheelchair service delivery (products and services).

SERVICE DELIVERY

I 75

Box 3.2. A wheelchair service network in Papua New Guinea
In Papua New Guinea, an estimated 50 000 people need a wheelchair. Throughout 2003 and 2004, governmental healthand rehabilitation organizations and national and international nongovernmental organizations developed a strategy forwheelchair provision. As a result, a pilot wheelchair service network, closely linked to the existing health and rehabilitation
services, was set up.
The wheelchair service network consists of a “regional wheelchair service” supporting four “satellite wheelchair
services”. The regional service is based at the National Orthotics and Prosthetics Service in Lae. At the regional service,technical personnel from the National Orthotics and Prosthetics Service team and physical therapy personnel from Lae’s
Angau Hospital together carry out assessment, prescription, ﬁtting, user training and follow-up. The National Orthotics
and Prosthetics Service provides repair services for users. This mixture of clinical and technical facilities has made thesetting up of the wheelchair service relatively easy, and the recent provision of dedicated premises for the service has
given it a stronger identity.
Two of the satellite services are based in local hospitals, one in a local prosthetic unit and one in a local communitybased rehabilitation service. The community-based rehabilitation link with each service is strong. The communitybased rehabilitation networks provide excellent referral, and the personnel work with hospital-based personnel toprovide users with a wheelchair.
Training in basic wheelchair service delivery for all of the clinical and technical personnel involved in the service
network was provided over two weeks by the international nongovernmental organization Motivation. Further support
for both clinical and technical personnel for one year was provided by a volunteer physiotherapist.
The network has the capacity to provide 25 wheelchairs per month. This is still not suﬃcient to meet the needs in
Papua New Guinea. However, through the success of this pilot exercise in using existing services and personnel, muchhas been learnt about the role of wheelchair services. In future, all stakeholders are keen to see the establishmentof more satellite services, as well as an increase in the capacity of the network to meet the needs of users with more
complex needs.

3

7 6 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S(#'L]ZZaX]V^ghZgk^XZYZa^kZgn(#'#&HiZeh^chZgk^XZYZa^kZgn
The functions of wheelchair services are described in Section 3.1. Wheelchair services are commonly
delivered in a sequence of steps. A summary of eight key steps typically involved in wheelchair
service delivery is given in Table 3.2 (4,5). Further details about each step and recommendations
on good practice are provided in Section 3.3.

Table 3.2. Key steps typically involved in wheelchair service delivery
Step
1. Referral andappointment

2. Assessment
3. Prescription(selection)

4. Funding andordering
5. Productpreparation

6. Fitting

7. User training
8. Follow-up,
maintenanceand repairs

Summary
The system of referral will depend on existing services in the
country. Users may self-refer or be referred through networks
made up of governmental or nongovernmental health andrehabilitation workers or volunteers working at community,
district or regional level. Some services may need to actively
identify potential users if they are not already receiving any
social or health care services or participating in school, work orcommunity activities.
Each user requires an individual assessment, taking into accountlifestyle, vocation, home environment and physical condition.
Using the information gained from the assessment, a wheelchairprescription is developed together with the user, family member
or caregiver. The prescription details the selected wheelchair
type, size, special features and modiﬁcations. Also detailed is
the training the user needs to eﬀectively use and maintain thewheelchair.
A funding source is identiﬁed and the wheelchair is ordered fromstock held by the service or from the supplier.
Trained personnel prepare the wheelchair for the initial ﬁtting.
Depending on the product and service facilities, this may include
assembly, and possible modiﬁcation, of products supplied bymanufacturers or production of products in the service workshop.
The user tries the wheelchair. Final adjustments are made toensure the wheelchair is correctly assembled and set up. If
modiﬁcations or postural support components are required,additional ﬁttings may be necessary.
The user and caregivers are instructed on how to safely andeﬀectively use and maintain the wheelchair.
Follow-up appointments are an opportunity to check wheelchairﬁt and provide further training and support. The timing depends
on the needs of the user and the other services that are available
to them. The service may also oﬀer maintenance and repairs fortechnical problems that cannot be easily solved in the community.
It is appropriate to carry out follow-up activities at the community
level as much as possible. If the wheelchair is found to be no longer
appropriate, a new wheelchair needs to be supplied starting again
from step 1.

SERVICE DELIVERYI(#'#'JcYZghiVcY^c\^cY^k^YjVajhZgcZZYhWhen planning wheelchair service delivery, it is important to recognize that each user has a unique
set of needs. These needs can be categorized as:t physical – the user’s health situation and postural and functional needs;
t environmental – where users live and where they need to use the wheelchair; andt lifestyle – the things users need to do in the wheelchair to lead their chosen way of life.
Physical needs. Some users will have a more complex mix of physical needs than others. Users withpostural deformities, reduced skin sensation and problems with muscle tone (for example spasticity)
will require an assessment conducted by personnel with appropriate skills and knowledge. Theseusers will also require more frequent follow-up and support. Three degrees of postural need andtheir relationship to the skill and support required from the personnel are described in Table 3.3.

Table 3.3. Postural needs of users related to the need for personnel skill and support
User
Users of manual wheelchairs
without modifications
Children or adults who can
sit well without any posturaldeformities or abnormalities.

Needs
Mobility and postural support for comfort,
function and the prevention of posturalproblems associated with permanent
wheelchair use.
Mobility and postural support provided
through a well-ﬁtted wheelchair and seatcushion.
Mobility and postural support to stabilize
posture for comfort, function and preventionof further postural problems.

Users of complex supportive
seating and mobility equipment
Children or adults withcomplex, ﬁxed posturaldeformities. Even withsupport, many cannot sit
normally.

Mobility and individually prescribed andcustomized wheelchairs to provide postural
support and accommodate ﬁxed deformities.

Supportive seating provided throughindividual modiﬁcations to a basic
wheelchair, or a specialized seating system.

3d support
ed of skill an
Increased neUsers of manual wheelchairs
with supportive seatingChildren or adults withmild to moderate posturaldeformities or tendencies.
If unaddressed, thesedeformities will limit comfort,
health and function.

7 8 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

Environmental and lifestyle needs. These factors require consideration during the assessment.
They will influence the choice of a wheelchair, based on performance characteristics, durability andother features. This is discussed in Chapter 4.
Box 3.3. Needs for wheelchair modifications and postural support additions in South Africa
How many users require more than basic wheelchair provision?
Owing to a general lack of statistics, it is not possible to state accurately how many users fall into each of the groups
described in Table 3.3. However, in a survey of 147 users conducted at the Western Cape Rehabilitation Centre in South
Africa in 2006, it was found that 58% of users required some form of wheelchair modiﬁcation or basic postural support.
Some 22% required complex postural support, while only 20% were able to use a basic manual wheelchair without any
modiﬁcation.
A supervisory chief physiotherapist states: “Since our service began, we have found that many users need more thanjust a basic wheelchair. Many have deformities from living so long without a wheelchair and now need their wheelchair
modiﬁed so that it ﬁts them. We also have more and more children with cerebral palsy coming to us, and they need
wheelchairs with extra postural support.”(#(<ddYegVXi^XZ^cl]ZZaX]V^ghZgk^XZYZa^kZgn
This section of the guidelines can be used to help in planning and initiating wheelchair services
and in evaluating existing services. Recommendations are presented in nine areas: good practicein overall service and for each of the eight key steps in wheelchair service delivery.

(#(#&DkZgVaahZgk^XZ
Good practice in wheelchair service includes the following.
t Wheelchair services recognize users as clients of the service and adopt a “client-centred approach”.
This means, inter alia, that:t VTFST SFDFJWF JOGPSNBUJPO BCPVU UIF QSPDFTT UIF XIFFMDIBJS TFSWJDF XJMM VTF UP QSPWJEF B
wheelchair, and the rights and responsibilities of the user in this process;t VTFSTBSFBDUJWFMZJOWPMWFEBTNFNCFSTPGUIFTFSWJDFUFBNJOBMMTUFQTMFBEJOHUPUIFQSPWJTJPO
of their wheelchair; andt TFSWJDFTBDUJWFMZDPMMFDUGFFECBDLGSPNVTFSTBCPVUUIFJSPQJOJPOPGUIFTFSWJDFBOEIPXJUNBZ
be improved.
t The service is equally accessible to all users, regardless of gender, age, ethnicity, religion or social
status.
t The service has personnel trained in its clinical, technical and training roles, who work closelywith users to provide advice, assessment, prescription, fitting, training and follow-up.
t The service has a designated service manager or coordinator.
t A referral network is in place.
t The service is well integrated with other rehabilitation and health services.
t Services are knowledgeable about the range of wheelchairs available locally.
t Services are able to offer more than one type of wheelchair, giving the user a choice based on
the assessment.

SERVICE DELIVERY

I 79

t Wheelchairs are sourced from a range of suppliers, including local and international, dependingon their appropriateness and affordability.
t Services carry out quality control to ensure that every wheelchair is assessed for safety before theuser tries it and for safety and correct fit before each user leaves the workshop or rehabilitation
centre with the wheelchair.
t Repair services are available to provide continuing support to users.
t Services identify local needs and measure their effectiveness in meeting these needs throughregular monitoring and evaluation (see Section 3.5).
t Services promote teamwork between clinical and technical personnel in providing service tousers.

(#(#'GZ[ZggVahVcYVeed^cibZcih
DW_ZXi^kZ
The objective of good practice in referrals and appointments is to ensure that users have equitable
access to wheelchair service delivery, to increase the efficiency and productivity of the service, andto minimize waiting lists.

GZ[ZggVahnhiZb
This pertains to the way in which users access the service. This may be through “self-referral”,
whereby users contact the service directly, or through a “referral network”, whereby users arereferred by another organization.

6eed^cibZcihnhiZb
This refers to the method of establishing appointment times with users for assessment andprescription, fitting, basic user training and follow-up. The most common method is to list
appointment times in a service diary, which are then filled as users are referred. The benefits of an
appointment system include reduced waiting times and increased work efficiency.

LV^i^c\a^hih
Where there is high demand for the wheelchair service, a waiting list will need to be established.
Users on the waiting list can be offered an appointment as the service works through the list. The
administration of appointments will depend on the context.

Box 3.4. Good practice in appointment and referral systems
When a user is referred to the service, a ﬁle is established and an appointment is made or the user is put on thewaiting list.
Q
Services provide training for referral network personnel to increase their awareness of wheelchair service delivery
and to show them how to refer users to the service.
Q
Services develop and distribute a form for referral network agencies to complete when referring users.
Q
Services use clear guidelines to prioritize appointments. This is particularly important where there are waiting lists.
Examples of high-priority users include those with a terminal illness and those at risk of developing life-threatening
secondary complications such as a pressure sores.
Q
Services set targets and measure their performance in relation to the number of referrals, the length of time between
referral and appointment, and reduction of waiting lists.
Q
Services have a screening procedure to minimize the scheduling of inappropriate referrals.
Q3

8 0 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S(#(#(6hhZhhbZci
DW_ZXi^kZ
The objective of good assessment practice is to accurately assess the needs of each individual user
in order to prescribe the most appropriate wheelchair available.
Every user requires an individual assessment, carried out by a person or persons with the appropriate
skills. The assessment should be holistic, taking into account the lifestyle, living environment andphysical condition of the user. It is important that the user and, if appropriate, the family are fully
involved in the assessment. Depending on the complexity of the needs, an assessment can takeup to 2 hours.

Fig. 3.1. Assessment of a user

Box 3.5. Good practice in assessment
Assessments are carried out in a private, quiet and clean space. This may be a dedicated space within the wheelchair
service, at another health care or community facility, or at the user’s home.
Q
Assessments are carried out by trained personnel. Culture, age and gender sensitivity while carrying out assessments
increases credibility and acceptability.
Q
Equipment for the assessment is readily available, including an assessment bed (plinth, mat, table), measuring tape,device for measuring angles (goniometer), foot blocks and infection control supplies.
Q
Assessment takes into consideration the user’s physical condition; home, school, work and other environments where
the wheelchair is used; lifestyle; size and age.
Q
Assessments are clearly documented on an assessment form and ﬁled for future reference.
Q
Where a service is unable to meet the user’s needs owing to the lack of an appropriate product or personnel with
suﬃcient skills, the service either:t SFGFSTUIFVTFSUPBOPUIFSTFSWJDFUIBUJTTUBõFEBOEFRVJQQFEUPTFSWFUIFVTFS XIFSFBWBJMBCMF t IPTUTPVUSFBDIWJTJUTPGNPSFRVBMJmFEQFSTPOOFM PSt EPDVNFOUTUIFVTFSTOFFETUPIFMQCVJMEBQJDUVSFPGVONFUOFFETUPHVJEFGVUVSFTFSWJDFEFWFMPQNFOUQSERVICE DELIVERY

I 81(#(#)EgZhXg^ei^dc
DW_ZXi^kZ
The objective of good prescription practice is to match the needs of the user, as identified throughthe assessment, with the most suitable wheelchair available.
Wheelchairs need to be available in different types and sizes and with different options. The
prescription (or selection) represents the process of matching the needs of the user with the mostsuitable available wheelchair. The completed prescription form is a full description of the wheelchairrequired and selected by the individual user.
Box 3.6. Good practice in prescription (or selection)
Users are given the opportunity to see and, where possible, try samples of wheelchairs, cushions and postural support
components. This assists users and personnel together in selecting a wheelchair and the necessary features.
Q
The importance of features is prioritized to help to make the most appropriate choice from what may be a limited
range of available wheelchairs.
Q
Each wheelchair prescription is documented, either on the assessment form or on a dedicated prescription form. The
prescription details:t UIFUZQFBOETJ[FPGXIFFMDIBJSt BOZBEEJUJPOBMDPNQPOFOUTSFRVJSFE GPSFYBNQMFQSFTTVSFSFMJFGTFBUDVTIJPO t BOZNPEJmDBUJPOTPSDVTUPNDPNQPOFOUTSFRVJSFEBOEt UIFJOGPSNBUJPOPSTLJMMTUIBUUIFVTFSOFFETUPLOPX PSCFBCMFUPQFSGPSN CFGPSFMFBWJOHUIFTFSWJDFXJUIBOFX
wheelchair.
Q
Wheelchair service personnel are given time to write up assessment and prescription notes immediately after eachappointment.
Q
Services give users an estimate of when their wheelchair will be ready (depending on funding, see below). Where
possible, an appointment for the user’s ﬁtting is made at the time the prescription is made.
Q3

8 2 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S(#(#*;jcY^c\VcYdgYZg^c\
DW_ZXi^kZ
The objective of good practice in funding and ordering is to order or procure the selected wheelchairfor the user, as early as possible.

;jcY^c\Following prescription, it is possible to closely estimate the cost of the product being recommended.
For most services, it will be essential to ensure a funding source has been identified before an ordercan be placed for equipment. Wherever possible, this should be in the hands of administrative rather
than clinical or technical personnel. See section 5.4 for more information on funding.

DgYZg^c\
When not in stock, wheelchairs need to be ordered from an external supplier or procured fromthe wheelchair service workshop, which usually maintains a stock of different sizes and types ofwheelchair.
Box 3.7. Good practice in ordering
If a wheelchair is not immediately available, services inform the user when the wheelchair will be ready for ﬁtting.
Services maintain a stock of wheelchairs and components to ensure faster delivery times.
Q
Services encourage suppliers to develop clear order forms and procedures.
Q
Services agree with suppliers on delivery times and aim to minimize delays.
Q
Services ensure ordering is completed within two working days of completing the user’s prescription, provided thatfunding is in place.
Q
Services have a system in place to monitor pending orders from suppliers.
Q
Services have a system for providing feedback to suppliers about quality issues.
Q
Q(#(#+EgdYjXiegZeVgVi^dc
DW_ZXi^kZ
The objective of good practice in product preparation is to prepare the wheelchair for the fitting,including modifications or custom postural support components.
Box 3.8. Good practice in product preparation
Each wheelchair being prepared is labelled with the user’s name and a serial number or bar code.
Modiﬁcations to wheelchairs (permanently altering the frame or a component of the wheelchair) are carried out
only by personnel with the appropriate knowledge and skills, since any such modiﬁcation may have structural andfunctional implications.
Q
The production and installation of custom seating systems or individual postural support components should
be carried out by personnel with the appropriate knowledge and skills. This work should also be done in close
collaboration with the assessment personnel.
Q
All mobility equipment is checked for quality and safety before the user tries it.
Q
Q

SERVICE DELIVERYI 83(#(#,;^ii^c\
DW_ZXi^kZ
The objective of good practice in fitting is to ensure that the selected wheelchair has been correctly
assembled and to make final adjustments to ensure the best fit.
Fitting is a critical step. At the fitting, the user and clinical and technical personnel ensure that thewheelchair fits correctly and supports the user as intended. A fitting may take between 30 minutes
and 2 hours or more, depending on the complexity.
During fitting, the user and competent personnel together check that:t the wheelchair is the correct size;t the wheelchair is correctly adjusted for the user;t any modifications or postural support components are fitting correctly; andt the wheelchair meets the user’s mobility and postural support needs and minimizes the risk of
the user developing secondary deformities or complications.

Fig. 3.2. Fitting the wheelchair to its user3
Box 3.9. Good practice in fitting
All users have their wheelchair individually ﬁtted by personnel trained to do so.
Whenever possible, ﬁtting is carried out by the same personnel that assessed the user.
Q
The ﬁt of the wheelchair (including any seating or postural components) is ﬁrst assessed with the user sitting in thestationary wheelchair. When the ﬁt is acceptable, it is then further assessed while the user self propels or is pushed.
Q
If the wheelchair ﬁt is not acceptable, further adjustments are made. If an acceptable ﬁt cannot be achieved,
alternative equipment or a reassessment may be necessary. The wheelchair cannot be provided to the user until theﬁt is acceptable.
Q
There is provision for more than one ﬁtting appointment for users with more complex needs, such as those withpostural deformities.
QQ

8 4 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S(#(#-IgV^c^c\d[jhZgh![Vb^a^ZhVcYXVgZ\^kZgh
DW_ZXi^kZ
The objective of good practice in training is to ensure that all users are given the information andtraining they need to be able to use their wheelchair safely and effectively.
Key areas of user training include:t how to transfer in and out of the wheelchair,t how to handle the wheelchair;t basic wheelchair mobility;t how to stay healthy in the wheelchair – for example prevention of pressure sores;t how to look after the wheelchair and cushion and, if appropriate, dismantle and reassemble thewheelchair; andt who to contact in case of problems.

Fig. 3.3. Wheelchair mobility training with peer trainer

Box 3.10. Good practice in basic training of users
A user training checklist is completed together with the user, covering the skills the user needs to have in order ofpriority. The checklist is used by the trainer, and as each skill is taught and demonstrated by the user it is checked oﬀ.
Q
Where possible, peer trainers (active users with strong wheelchair skills and training in how to teach and support
other users) provide basic user training, with supervision by clinical personnel.
Q
Wheelchair services link closely with any user groups in the community, providing peer training to strengthen
training given at the service.
Q
Written or visual materials, including pamphlets or posters in local languages, are used to assist the training of users.
Q

SERVICE DELIVERY

I 85(#(#.;daadl"je!bV^ciZcVcXZVcYgZeV^g
DW_ZXi^kZ
The objective of good practice in follow-up, maintenance and repair is to evaluate the effectivenessof the wheelchair in maximizing the user’s functioning, comfort and stability, and to ensure thatthe equipment has been maintained appropriately and is in good condition.
Follow-up should include a review of:t how well the wheelchair has worked for the user;t any problems the user has had in using the wheelchair;t the wheelchair’s fit, in particular checking that the wheelchair is providing good postural support
for the user;t the user’s skills, and whether further training is required;t the condition of the wheelchair and whether any adjustments or repairs are required; andt the user’s ability to care for and maintain the wheelchair, and whether any further training isrequired.
The frequency of follow-up will depend on the individual needs of the user. Some users should be
followed up more frequently than others. As a guide, follow-up appointments are usually madewithin six months of receiving a wheelchair. Basic wheelchair repair work can often be done locallyat bicycle or car repair workshops.

Box 3.11. Good practice in follow-up
Whenever possible, all members of the wheelchair service team are involved in follow-up appointments. This includes
clinical, technical and training personnel.
Q
The frequency of follow-up is determined by the individual needs of the users.
Q
Follow up appointments are given as a priority to users in the following categories:t DIJMESFO XIPTFOFFETDIBOHFRVJDLMZBTUIFZHSPX t VTFSTBUSJTLPGEFWFMPQJOHQSFTTVSFTPSFT
t VTFSTXIPIBWFBXIFFMDIBJSXJUIQPTUVSBMTVQQPSUNPEJmDBUJPOTPSBEEJUJPOTBOEt VTFST PSGBNJMZNFNCFSTDBSFST XIPIBWFIBEEJöDVMUZJOGPMMPXJOHUIFCBTJDUSBJOJOHHJWFOBUUIFTFSWJDF
Q
Services use follow-up appointments as an opportunity to gather feedback from the user to help evaluate the qualityof the service provided.
Q3

8 6 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S(#)EZghdccZa^cl]ZZaX]V^ghZgk^XZYZa^kZgn
A summary of the major groups of personnel involved in wheelchair service delivery, including
manufacturers and suppliers, referral networks and service personnel, is shown in Fig. 3.4.

Fig. 3.4. Organizations and personnel involved in providing an appropriate wheelchair to a user
Referral networks
E.g. governmental andnongovernmental health andrehabilitation personnel

USER

Manufacturers or suppliers
Managers and technical personnel

PRODUCTpp

Servicepersonnel
Service team roles:
Q management
Q clinicalQ technical
Q training
Support personnelp(#)#&BVcj[VXijgZghdghjeea^Zgh
Wheelchair services usually receive wheelchairs from manufacturers or suppliers. The scope of theseguidelines does not allow a discussion of all production and supply personnel, but a few points are
made here concerning managers and technical production personnel.

BVcV\ZbZci
As well as day-to-day management, managers of wheelchair production facilities are responsible fordesign selection and production quality. It is therefore important that managers receive feedback
from users and wheelchair services about how well their wheelchairs meet their needs.

IZX]c^XVaegdYjXi^dceZghdccZa
Technical production personnel are concerned with the technical side of wheelchair production.
They are not necessarily involved in the fitting or modification of wheelchairs for individual users.
This differs from technical personnel in wheelchair services, who are involved in the assembly,
modification and fitting of wheelchairs for specific individuals. Nevertheless, some technicalpersonnel, typically those in smaller workshops, may be involved in both the manufacture and fittingof wheelchairs. The term “technical production personnel” as used in these guidelines is limited towheelchair manufacturers and does not include the provision of services to individual users.

SERVICE DELIVERYI 87(#)#'GZ[ZggVacZildg`hReferral networks play a crucial role in wheelchair service delivery. Well-functioning referral
networks help to ensure services are accessible to users. Referral networks may consist of healthand rehabilitation personnel or volunteers working at community, district or regional level.
The importance of a strong link between specialist services and rehabilitation or health careprogrammes is stressed in a joint statement of the International Society for Prosthetics and Orthotics
and WHO (6).
Wheelchair services are an example of a specialized service that cannot always be fully provided
within every community. In developing countries, the majority of those people with disabilities livein rural areas and find it difficult to access rehabilitation services, which are often restricted to large
cities (7,8). Health and rehabilitation workers therefore need to play a proactive role in ensuringthat people living in rural areas can also access wheelchair services without difficulty.
The role of referral networks in wheelchair service delivery can include:t identifying and referring people requiring wheelchairs;t liaising between the users, their families and the wheelchair services to facilitate assessment,
fitting and follow-up;
t reinforcing wheelchair service training such as pressure sore prevention, prevention of secondary
complications, wheelchair maintenance and mobility skills;
t providing support, advice and possibly assistance in adapting the user’s home environment;t encouraging measures to facilitate accessibility in the community;t providing information to the wheelchair services about the acceptability and use of prescribed
wheelchairs;
t assisting the user to arrange repairs, andt promoting the benefits of wheelchairs.

(#)#(HZgk^XZeZghdccZa
Wheelchair service personnel carry out managerial, clinical, technical and training duties (see Fig.
3.4). These roles may be fulfilled by personnel from a range of training and educational backgrounds.
They may also overlap: in a small service, for example, one person could carry out both the clinicaland technical roles. In another scenario, one person could carry out the clinical, training andmanagement roles with the support of a part-time technician.
At times, particularly when working with users who have complex needs, personnel may draw
on the expertise of other specialists such as occupational therapists, physiotherapists, speech
and language therapists, paediatricians, neurologists, physiatrists, orthotists, prosthetists andorthopaedic specialists.

3

8 8 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

BVcV\ZbZcigdaZ
For a wheelchair service to operate effectively, a designated manager is critical. The manager
ensures a framework is in place to enable the wheelchair service to operate. This includes adequate
staffing, facilities, funding, products, referrals and appointment systems. Managers also play a keyrole in promoting wheelchair services. The manager therefore requires a thorough understandingof wheelchair service delivery in addition to general management skills.
The duties of wheelchair service managers should include:t building awareness of wheelchair service delivery among all stakeholders;t developing a referral network through promotion of the wheelchair service and its functions;t organizing training opportunities for referral network personnel;t ensuring the service is accessible to all users within the service area, including women, children
and minority groups;
t managing waiting lists;t identifying and securing sources of funding to support the service;t facilitating the development and training of service personnel;t evaluating the effectiveness of the service in meeting users’ needs;
t continuously improving service quality;
t developing links with disabled people’s organizations and community-based rehabilitation
programmes; andt assisting in the formation of wheelchair users’ groups.

8a^c^XVagdaZ
Clinical personnel work directly with the user in assessment, prescription, fitting and follow-up.
Ideally, the clinical personnel work closely with technical personnel, particularly on prescription
and fitting.
The main duties of clinical personnel include:
t wheelchair service delivery, following the eight-step process described in Table 3.2;
t quality control to ensure equipment is adjusted correctly and is safe for each user;t training users in mobility and health issues, or supervision of such training provided by atrainer;t follow-up with users to ensure that equipment continues to be appropriate to their needs;t record keeping and documentation;
t education of referral network personnel;t keeping up to date with the range of available wheelchairs; andt participation in overall service evaluation.

SERVICE DELIVERYI 89

IZX]c^XVagdaZ
Technical personnel ensure that the technical requirements of the prescription are met throughthe correct assembly or modification of the wheelchair. Technical personnel have direct contact
with users, at least in the prescription and fitting stages. When working with a user who requires
modifications or postural support, it is increasingly important that technical personnel are directly
involved in the user’s assessment, fitting and follow-up.
The main duties of technical personnel include:t assembling or preparing wheelchairs according to prescription;
t making or assembling modifications or custom postural support;t training users in wheelchair maintenance and basic repair, or supervising such training provided
by a trainer;t ensuring that each wheelchair and any modifications are technically safe before each fitting andbefore the user leaves the service with the new equipment;t keeping records and documentation;
t following up users to ensure equipment continues to be appropriate;t facilitating maintenance and repairs of wheelchairs and associated equipment; andt participating in overall service evaluation.

IgV^c^c\gdaZ
One of the key steps in wheelchair service delivery is basic skills training for wheelchair users. The
bulk of the training may be fulfilled by clinical or technical personnel or by dedicated trainers. They
also provide users with the necessary advice on maintaining their wheelchair. Experienced, welltrained wheelchair users (“peer trainers”) are useful in training other users (see Box 3.12). Provided
with the right resources and training, peer trainers may have some advantages over trainers who are
not users. Such advantages include an ability to empathize and to draw on first-hand experience.
For those receiving a wheelchair for the first time, there is added value in training given by a peer
trainer. By working with peer trainers, users are better able to recognize their own potential.
The main duties of trainers include:t training users and caregivers, individually or as a group, in:t USBOTGFSSBMJOBOEPVUPGUIFXIFFMDIBJSt XIFFMDIBJSIBOEMJOHt CBTJDXIFFMDIBJSNPCJMJUZt IFBMUIJTTVFTTQFDJöDUPXIFFMDIBJSVTF QSFTTVSFTPSFQSFWFOUJPO FUD
t XIFFMDIBJSNBJOUFOBODF
t participating in routine and more intensive follow-up for those users at risk, or who require
additional training and support;t educating referral network personnel; andt participating in service evaluation, focusing on the needs of users.
In addition, trainers could become involved in:t activities to promote the wheelchair service;t liaison with disabled people’s organizations and community-based organizations; andt referral of users to relevant community programmes such as disabled people’s organizations,vocational schemes and peer group training.

3

9 0 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

Box 3.12. Peer training in Romania
For 11 years now, the Motivation Romania Foundation (MRF) based in Bucharest has provided peer training. The MRF
wheelchair service and peer training programme is based on the principle that all wheelchair recipients should undergo peer
training (including, but not limited to, wheelchair skills) to maximize their independence. The peer training team currently
consists of four users and a physiotherapist. Each year, some 160 users access the peer training programme, which includes:
Q
training in wheelchair skills;
Q
individual and group discussions, in which users can talk about the challenges they have faced and try to ﬁnd
solutions together;Q
provision of information, for example about dealing with health problems; andQ
participation in sports and social activities to facilitate the development of outgoing, people-oriented attitudes andprevent isolation.
Peer training is carried out at the MRF centre and through regular peer training camps. Peer trainers are recruited fromamong former recipients of peer training. They receive training in teaching and counselling from experienced peergroup trainers, thus enabling them to take on the role themselves.
The costs of the peer training programme are covered by the Romanian Ministry of Labour and Social Protection, theNational Authority for People with Disabilities, and national and international donors.

DkZgk^Zl
Table 3.4 provides an overview of the clinical, technical, training and management duties ofwheelchair service personnel.

Table 3.4. Overview of the duties of wheelchair service personnel

Promoting the service
Sourcing funding
Developing referral base
Liaising with other organizations
Service evaluation
1. Referral and appointment
2. Assessment
3. Prescription
4. Funding and ordering
5. Assembly and/or production
6. Fitting
7. User training
8. Follow-up, maintenance and repairs
Training referral network personnel
Training service delivery personnel

ClinicalTechnical
Service management and development
Training

Management






Key steps in service delivery






























Training and professional development














SERVICE DELIVERY

I 91(#*Bdc^idg^c\VcYZkVajVi^dc(#*#&I]ZcZZYidbZVhjgZeZg[dgbVcXZ
Monitoring and evaluation of a wheelchair service can help identify those areas that are successful
and those that can be improved. Monitoring is the regular ongoing collection and analysis of
information to track the quality and effectiveness of the wheelchair service. Evaluation refers to an
overall evaluation, usually conducted over a short period of time. Evaluations are often carried out
annually or sometimes biannually. Information gained through regular monitoring is often usedas part of an overall evaluation.
It is recommended that services establish a system for regularly monitoring the service, and conduct
annual overall evaluations to assess service performance and impact.
Box 3.13. Purpose of monitoring and evaluating wheelchair services
Monitoring and evaluation can provide important information that enables services to:Q
improve the quality of services and productsQ
improve service processes such as referral, appointments and follow-up
Qcontain costs by increasing eﬃciency
Qdemonstrate the beneﬁts of wheelchair service delivery for usersQ
demonstrate the eﬀectiveness of the service
Q
identify and quantify unmet needsQplan further development of the service
Q
allocate resources appropriately
Qjustify current and proposed service fundingQ
develop stronger partnerships with service recipientsQ
enhance credibility and funding opportunities.

(#*#'Bdc^idg^c\
Regular monitoring can be established as follows.
1. Identify the areas and activities of the service that should be routinely monitored. Examples
are the rate of referrals, waiting times, the number of users receiving wheelchairs, the types ofwheelchair prescribed, the number of follow-ups and the level of user satisfaction.
2. Set “performance targets” for these areas and activities. A performance target is a statement of
how well the service would like to perform in that area. This may often be linked to funding. For
example, funding may have been provided to the service based on agreed objectives or targets.
Performance targets should be realistic, taking into account the resources available.
3. Identify the information that needs to be collected in order to be able to monitor service
performance for each area – and how it will be collected. Ideally, gathering information should bepart of the service’s normal record keeping, and should thus require very little additional work byservice personnel.

3

9 2 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G STable 3.5 provides an example of service areas that could be monitored, performance targets, andways to collect information for each service area. It is important to note that the performance targets
are examples only; actual targets need to be worked out according to the resources available toeach service.

Table 3.5. Examples of service areas that could be monitored, performance targets, and ways of collecting
information
Areas and activities

Example performance targets
Referral
Number of users referred
The service will receive 30 referrals per
month
Average waiting time from Waiting time from referral toreferral to appointment
appointment should be less than 1 month
Wheelchair provision
Number of users who receive The service will prescribe and ﬁt
a wheelchair
wheelchairs for 20 users per month
Number of follow-up
Follow-up appointments will be carriedappointments carried out
out for at least 15 users per month
Impact of wheelchair
Users receiving wheelchairs throughprovision on users
the service have a demonstrated
improvement in quality of life as a resultof their wheelchair

Information collection
Record referrals received
Record date referral received and assessment
date on user ﬁleWheelchair prescriptions recorded on users’ﬁles
Follow-up appointments documented inusers’ ﬁlesAssessment notes should indicate areas ofdesired improvement (e.g. function, posture)
Follow-up notes should indicate
improvements achievedUser feedback
Wheelchair population served
Number of men and women accessing the
The service will encourage equal access
Details of users referred toservice – recorded on user ﬁlesthe service, such as age,gender, disability, postural
The service will aim to meet the needs
Types of postural need presented andsupport needsof users requiring basic wheelchairs
wheelchairs prescribed – recorded on user
and those requiring modiﬁcations andﬁlespostural support
Geographical area covered by The service will provide wheelchairs forHome address of users accessing the service –the service
people living within (deﬁned region/area) recorded on user ﬁlesService costs
The individual cost of each wheelchair will Cost of products purchased – recorded in
Cost of products supplied,be less than (amount speciﬁed according service accounts
including modiﬁcations
to budget and realistic cost of available
made within the service
products)
Cost of materials and labour spent on
assembly and modiﬁcations – recorded on
workshop “job sheet” for each wheelchairprescribedStaﬀ time sheet, completed daily
Staﬀ are to spend __% of their time on
Amount of time spent
direct service delivery and __ % of theirby personnel on service
time providing education for referral
activities (assessment,
sourcesfollow-up, training, etc.)

SERVICE DELIVERYI 93;ZZYWVX`[gdbjhZgh
In addition to the routine collection of monitoring information, it is recommended that services
establish methods of regularly gathering feedback from users and their families. There are several
ways in which such feedback can be gathered.
t A few questions about the service can be formulated and put to users after they have received
their wheelchair.
t A short questionnaire can be developed, asking users for their thoughts on the performance ofthe service. This could be offered to every user or to a specified number of randomly selected
users each month.
t Users can be encouraged to write down their impressions of the service and post them in a
“feedback box”. Feedback can be anonymous, thus allowing people to feel more comfortable
about providing honest feedback. It is important to note that this type of system is open only
to those with a sufficient level of literacy, and should therefore not be the only method used togather feedback.

6cVanh^c\XdaaZXiZY^c[dgbVi^dc
The information collected through regular monitoring and user feedback will be most useful if it
can be centrally stored and organized. A basic database can be very useful for this where computersand personnel are available. Alternatively, information can be organized and analyzed manually.
Once information is organized, it is possible to measure how the service is performing against theperformance targets. A regular analysis of information can be used to identify problems and action
can be implemented to solve the problems. For example, if fewer referrals than expected are being
received, a service may choose to contact all referral sources to remind them about the service oroffer additional training.

(#*#(:kVajVi^dc
An overall evaluation is more comprehensive than ongoing monitoring. An evaluation provides
an overview, highlighting the service’s strengths and weaknesses. Previous evaluation reports canbe used as a basis for subsequent evaluations.
Service evaluations can be carried out externally or internally. An external evaluation involves having
one or more people from outside of the service carrying out the evaluation. This can be useful, as
external evaluators will view the service from a different perspective. Internal evaluations can be
carried out by one or more personnel who have been designated the responsibility to gather andanalyse the necessary information. The use of computers in data collection, programme monitoring
and follow-up will facilitate the evaluation of service provision.
Table 3.6 provides some suggestions for gathering evaluation information for some key service
areas.

3

9 4 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G STable 3.6. Suggestions for gathering evaluation information for some key service areas
Service area
Quality of service
delivery
Users served andthe intervention
they received

Cost of service,including costof products andservice delivery
Staﬃng(numbers of
personnel andtheir roles andcompetences)

Evaluation information
The good practice recommendations made in Section 3.3 of these guidelines can be used as
criteria to assist in evaluating the quality of service delivery.
Information from ongoing monitoring should enable evaluators to quantify the number of users
provided with a wheelchair, training and follow-up; the diﬀerent types of wheelchair provided;
and the number of users with needs that could not be met by the service. A thorough evaluation
would also include information on users accessing the service, including age, gender, ethnicity,disability and home location.
Information from ongoing monitoring should enable evaluators to review and summarize thecost of the service.
An audit of accounts may also be used to determine the cost of products and services.
Evaluators can assess numbers and roles of personnel by talking to service management orreviewing personnel records.
Staﬀ competences can be assessed by observing personnel carrying out their duties. Some of thegood practice recommendations in Section 3.3, the personnel roles described in Section 3.4.3
and the clinical competences summarized in Section 5.3.3 can be used as criteria to assist in
evaluating personnel competence.
Staﬀ educational records should be reviewed to help determine competences and professional
development.

Facilities andequipment
available to theservice
Impact on
users and theirfamilies

Feedback from users and individual interviews with personnel can help to identify strengths andweaknesses in the staﬃng structure.
Evaluators can assess the suitability of facilities and equipment by observing the service inpractice.
Feedback from users and individual interviews with personnel can help to identify any strengths
and weaknesses in service facilities.
Information may be gathered from users and their families on the impact of the service.
Measures can include increased participation in family or community activities (for example
education, employment in or outside of the home, participation in social activities) and increased
earning potential of wheelchair users or their families. Methods of gathering information include
the following.
t&WBMVBUPSTNBZSFWJFXBTTFTTNFOUBOEGPMMPXVQGPSNT"TTFTTNFOUGPSNTDBOQSPWJEF
information about users and their families before they receive a wheelchair through the service.
Follow-up reports can provide information about how the service has aﬀected the lives of theuser and his/her family.
t)PNFWJTJUTXJMMFOBCMFFWBMVBUPSTUPNFFUUIFVTFSTPGUIFTFSWJDFBOETFFGPSUIFNTFMWFTXIBU
impact there has been. Home visits may provide additional information not gained through afollow-up appointment carried out at the service.
t"EFUBJMFETVSWFZNBZCFEFWFMPQFEUPBTTFTTUIFTFSWJDFJNQBDUPOUIFRVBMJUZPGMJGFPGVTFST 
including participation in school, employment and other activities.
t6TFST BOEGBNJMZNFNCFST NBZCFHBUIFSFEBTBGPDVTHSPVQUPQSPWJEFFWBMVBUPSTXJUIinformation about how they believe the service has aﬀected them.

SERVICE DELIVERY

I 95

HjbbVgn
Wheelchairs need to be provided together with services.
Existing rehabilitation personnel can be utilized to provide wheelchair services.
Integrating wheelchair services with existing health or rehabilitation services is recommended.
Where possible, the needs of users should be met at community level.
Wheelchair services facilitate the assessment of individual user needs, provide an appropriate
wheelchair, train users and caregivers, and provide ongoing support and referral to otherservices.
t Each user has a unique set of physical, environmental and lifestyle needs..
t Groups of personnel involved in wheelchair service delivery include manufacturers and suppliers,
referral networks and service personnel.
t The main roles of service personnel are managerial, clinical, technical and educational.
t Peer trainers play an important role in wheelchair provisiont Wheelchair provision should be regularly monitored and evaluated, especially in helping to identify
those areas that are successful and those that need to be improved.
t
t
t
t
t

GZ[ZgZcXZh
1.
2.

3.
4.
5.
6.

7.
8.

Rushman C, Shangali HG. Wheelchair service guide for low-income countries. Moshi, Tanzanian Training Centre for Orthopaedic
Technology, Tumani University, 2005.
Sheldon S, Jacobs NA, eds. Report of a Consensus Conference on Wheelchairs for Developing Countries, Bangalore, India,
6–11 November 2006. Copenhagen, International Society for Prosthetics and Orthotics, 2007 (http://homepage.mac.com/
eaglesmoon/WheelchairCC/WheelchairReport_Jan08.pdf, accessed 8 March 2008).
McCambridge M. Coordinating wheelchair provision in developing countries. In: Proceedings of the RESNA 2000 Annual
Conference: Technology for the New Millennium, Orlando, Florida, 28 June – 2 July 2000. Atlanta, GA, RESNA, 2000:234–236.
The manual wheelchair and its use. Stockholm, Swedish Institute of Assistive Technology, 1990 (In Swedish).
Oderud T. Design. In: Report of a Consensus Conference on Wheelchairs for Developing Countries, Bangalore, India, 6–11 November
2006. Copenhagen, International Society for Prosthetics and Orthotics, 2007.
The relationship between prosthetics and orthotics and community-based rehabilitation. A joint ISPO/WHO statement.
Copenhagen/Geneva, ISPO/WHO, 2003 (http://www.who.int/disabilities/technology/po_services_cbr.pdf, accessed 10 March
2008).
Helander E. Prejudice and dignity: An introduction to community based rehabilitation, 2nd ed. New York, United Nations
Development Programme, 1999
Empowering the rural disabled in Asia and the Pacific. Rome, Food and Agriculture Organization of the United Nations, 1999
(http://www.fao.org/sd/PPdirect/PPre0035.htm, accessed 10 March 2008).

3



4

IG6>C>C<… to develop the skills and knowledge of personnel
involved in wheelchair provision.

The training guidelines:
t offer recommendations on how training
programmes may be provided; andt suggest training requirements and recommend
course content for personnel involved inwheelchair provision.

I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

Box 4.1.

Wheelchairs
ee c a s changing
c a g g lives
es …
Testimonial from a user in South Africa
Caitlin is three years old and lives in Cape To
Africa. Caitlin has cerebral palsy, is unable toand has great difficulty speaking. When she
turned two, Caitlin’s physiotherapist
suggested her parents get her a special
child’s wheelchair. At that time, Caitlin
spent most of the day lying on thefloor or in her parents’ arms. She wasvery frustrated and irritable, and criedoften. Her parents were referred to a small
wheelchair service in Cape Town, whereCaitlin was assessed. The service prescribeda wheelchair with a special insert to help
support Caitlin. Her parents had to raise
funds to pay for the wheelchair, which she
received just as she turned two.
Caitlin’s parents say: “When we first sat Caitlin down in her new wheelchair, to ouramazement she immediately knew what to do. Ever since then we have noticed amajor difference and improvement in Caitlin. She is less frustrated, more motivated,enjoys being independent, loves chasing other kids while sitting in her wheelchair andthoroughly enjoys the outdoor life. The chair has given Caitlin and us new found hope forthe future, and a normal life as far as possible. Believe it or not, for two years we did notknow we had a child in the house, but with this chair our princess is doing her thing andis always up to mischief.”
Caitlin is happier and more active since she received her wheelchair. She is also making
good physical progress. Her therapists report that her overall posture has improved,that she is stronger and that she has bettimproved, owing to her improved postu
language as a means of broadening thettestimonial
testimoti i

TRAINING

I 99)#&>cigdYjXi^dc
EjgedhZVcYdjiejih
The purpose of the training guidelines is to develop the skills and knowledge of personnel involvedin wheelchair provision.
Implementation of the training guidelines will contribute to:t an increase in the number of personnel trained in wheelchair provision;t an improvement in the competences of wheelchair provision personnel;t greater recognition for personnel trained and practising in the field of wheelchair provision;t greater integration of wheelchair provision within rehabilitation services; andt increased collaboration among those involved in the development, implementation andmaintenance of wheelchair provision training programmes.

HigViZ\^Zh
Effective wheelchair provision requires that personnel have the appropriate knowledge and skills.
The following provides some strategies to assist in developing training opportunities and initiatives(1). The United Nations Standard Rules concerning “personnel training” indicate that countries are
responsible for ensuring the adequate training of personnel, at all levels, involved in planning andproviding programmes and services for people with disabilities (2). This is confirmed in Article 4 of
the Convention on the Rights of Persons with Disabilities (3).

>YZci^[n^c\XVcY^YViZh[dgigV^c^c\
Existing health or rehabilitation personnel could be easily trained for wheelchair provision. Possible
candidates for training usually are: community health care workers, community-based rehabilitation
workers, occupational therapists, physiotherapists, prosthetists, orthotists, local craftsmen andtechnicians. Users comprise another group of potential candidates: although they may lack
professional training, users already have a fundamental understanding of their needs and may behighly motivated. Studies indicate that wheelchair skills training for manual wheelchair users is
efficacious, safe and practical (4).

4

1 0 0 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G SA^c`^c\l^i]Zm^hi^c\igV^c^c\egd\gVbbZhVcYhX]ddah
Linking with existing rehabilitation training programmes and schools provides an opportunity
to conserve resources. Links may be established with many of the training programmes currently
being implemented in less-resourced settings, including community-based rehabilitation training
programmes, training programmes for middle-level rehabilitation workers, occupational therapy
and physiotherapy schools, and prosthetics and orthotics training schools. Existing rehabilitation
training schools may offer separate programmes in wheelchair provision (exclusive training
approach) (5), as well as accommodate some modules related to wheelchair provision into existing
training programmes (integrated training approach).

Box 4.2. Examples of exclusive and integrated approaches to wheelchair-related training
Exclusive training
The one-year Wheelchair Technologists Training Course
at the Tanzanian Training Centre for Orthopaedic
Technologists is an example of exclusive wheelchairtraining.
Another example is the three-week courses on wheelchairprescription and wheelchair assembly oﬀered by Mobility
India.

Integrated training
At the Centre for the Rehabilitation of the Paralysed in
Bangladesh, training on wheelchair services is integrated
into the curriculum for occupational therapy students.
Also, Mobility India has integrated a three-week module
on wheelchairs into its one-year training programme forrehabilitation therapy students.

9ZkZade^c\bdYjaVgigV^c^c\eVX`V\Zh
To minimize the time and financial resources required for training, it is suggested that training
be developed and provided in modules at different levels, starting with basic wheelchair service
delivery. After the successful completion of the first-level modules, personnel would be able
to provide basic wheelchair services. Each successive level would enable personnel to provide
wheelchairs for users with increasingly complex needs. Suggested content for the basic andintermediate levels are provided in Section 4.3. Recognizing that many users require more than basic
wheelchair provision, it is suggested that training programmes plan that at least some personnel
progress to an intermediate level of training as soon as possible.
Training packages that include a trainer’s guide and student workbooks can enable training to berepeated consistently by different trainers. Such packages could be developed to support training
in more than one setting, with small adaptations made to match the specific context. This approach
can reduce the time required to plan and prepare training and thus help reduce the resources
required.

:meadg^c\lVnhidZchjgZigV^c^c\^hgZXd\c^oZYRecognition of skills attained is an important incentive for personnel undergoing training. It also
helps to increase the perceived importance of wheelchair provision. It is therefore recommended
that those developing and running training courses seek official recognition of their courses.
Recognition can be sought nationally, through educational bodies such as schools providing
health care or rehabilitation training, or through international professional associations ororganizations.

TRAINING

I 101

7j^aY^c\i]ZXVeVX^ind[adXVaeZghdccZaidegdk^YZigV^c^c\
To maintain training programmes locally, it is important to develop the capacity of local trainers(6); and in order to train effectively, practical experience in the field is necessary. Some strategies
for developing local trainers include the following.
t When setting up a training programme, select strong candidates with the potential to become
trainers. Train these people in basic wheelchair provision and, after field practice, in moreadvanced wheelchair provision. After two or three years, these personnel should have thepotential to train others in basic wheelchair provision. To assist them in this role, training in “howto deliver training” would be of benefit.
t Ensure local trainers continue to practise their skills in the field. This will increase the quality ofthe training they are able to deliver.
In the absence of local trainers, there are international organizations that may assist in providing
training (see Annex A). An example of such training is given in Box 4.3.

Box 4.3. “Fit for Life” wheelchair prescription training package
Motivation has developed a training course aimed at wheelchair
service personnel working in less-resourced settings. To enable it to
be delivered consistently by diﬀerent trainers, the course has been
documented and “packaged”. The training package includes a student
workbook, a trainer’s guide and teaching aids such as poster-size
visual aids, assessment methods and card games.
Fictitious characters are used throughout the course to provide a rangeof diﬀerent case study scenarios to reinforce the trainees’ learning.
In the ﬁrst version of the package, illustrations have been designed
to represent a range of Asian nationalities and religions, allowing
the course to be used in a wide range of settings in Asia. For settingsoutside this region, it would be appropriate to adapt the illustrations.
The trainer’s guide contains overall information on how to deliver
the course, as well as lesson plans for each session. Each lesson plan
includes the time and materials required for that session and step-bystep instructions on how to teach the session.
The development of the course took two years. The training package enables diﬀerent trainers to deliver the course,
and provides a consistent level of training and student assessment. The training package has also been used by otherorganizations, made possible by the development of the trainer’s guide and teaching aids.

4

1 0 2 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

HiV`Z]daYZghVcYgZhdjgXZhStakeholders involved in planning, implementing and participating in training programmes
include:t national government authorities responsible for health and education, and other relevant
departments and local authorities;t supporting organizations providing technical input and funding; andt trainers and trainees.
Key resources required to implement the training guidelines include:t training packages and training materials;
t training facilities, including premises for delivering interactive theoretical training, workshop andclinic facilities for practical sessions, and areas for wheelchair mobility training;t a reliable supply of wheelchairs that meet minimum requirements;t trainers with experience in wheelchair provision; andt users willing to participate in sessions.

)#'IgV^c^c\gZfj^gZbZcih
This section describes the training requirements for referral network personnel and those directly
fulfilling management, clinical, technical and training roles in a wheelchair service. See Section 3.4
for a description of the different roles and Section 4.3 for recommended course content.

)#'#&GZ[ZggVacZildg`hBasic training for personnel working within referral network organizations (for example healthand rehabilitation personnel and volunteers working at community, district or regional level) will
increase the effectiveness of a referral network. Ideally, training would provide referral personnel
with a combination of:t core knowledge and skills (relevant to all referral personnel regardless of context), including theability to identify those who would benefit from being referred to a wheelchair service and anunderstanding of how best to support users in the community; andt local knowledge, including familiarity with the operations of local wheelchair services and anawareness of locally available products.
Training for referral network personnel can be delivered in a number of ways.
t Wheelchair services can host “referral network training” run by the clinical, technical and possibly
training personnel of the service. Such training programmes would help to strengthen thereferral network for that service as well as providing an opportunity to strengthen the working
relationships between referral and service personnel.
t Existing training programmes for health and rehabilitation employees can choose to include
basic wheelchair referral for all personnel. This would serve to ensure that all personnel passing
through these programmes have a greater awareness of the needs of users, how to refer users,
and how to support users in the community. Training should cover the function of a wheelchair
service and the value of assessment, prescription, user training and follow-up.

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I 103

For both of these approaches, preparations for training could be reduced by the development oftraining packages covering the core knowledge required by referral network personnel, including
guidelines for adapting the package to include local knowledge.

)#'#'GdaZd[l]ZZaX]V^ghZgk^XZegdk^YZgh
BVcV\ZbZci
Managers require generic skills in service management, such as financial and personnel management.
These skills are not unique to wheelchair provision: management training opportunities exist in
many settings. In addition to generic management skills, wheelchair service managers require agood overall understanding of wheelchair provision. Such an understanding will enable a manager
to support service personnel, promote the wheelchair service, and evaluate the effectiveness ofthe service.
The availability of short courses for wheelchair service managers would be an asset in thedevelopment of wheelchair services. Such training should include elements of wheelchair provision,
fundraising, development of referral networks and wheelchair service evaluation.

8a^c^XVaVcYiZX]c^XVa
Trainee selection: Selection of candidates for training should be flexible and in accordance withexisting rehabilitation and health care staffing structures. Ideally, training should be accessible toapplicants from a broad range of backgrounds and not wholly dependent on formal pre-entry
qualifications. Nevertheless, for the training to be recognized, the relevant training regulations
may have to be followed.
Wherever possible, entry requirements should take into account:t candidates’ practical, hands-on experience with users and wheelchair provision;t any informal training they have received;t the level of formal education they have attained; andt their experience in the delivery of any health care service.
Given quality training and support, personnel from a range of professional/clinical/technicalbackgrounds can competently carry out the duties required in providing wheelchairs to most users.
Box 4.4 describes possible candidates. It is important to note that the technical role in a wheelchair
service requires the personnel to work directly with the user. Those selected to train in the technicalfield should therefore have skills in working with people as well as technical skills. All candidates
will need to be able to read and write competently in their mother tongue.
Box 4.4. Professional/clinical/technical candidates for training
Community-based rehabilitation workers or volunteers.
Personnel working in a wheelchair service with no previous training or academic qualiﬁcations.
Q
Qualiﬁed nurses, physiotherapists, occupational therapists, prosthetists, orthotists, doctors and other health andrehabilitation workers.
Q
Users interested in working with other users in a clinical role.
QQ4

1 0 4 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

In clinical roles it is better to have qualified medical, paramedical or rehabilitation professionals witha good knowledge of anatomy, physiology, different health conditions, rehabilitation needs andpossible solutions. While the clinical role concentrates on the user, the technical role has more to
do with the wheelchair, such as selecting the correct size and components, assembly and necessary
modifications.
Candidates for courses in wheelchair provision for users with complex needs must hold a degree
or diploma in occupational therapy, physiotherapy, prosthetics or orthotics. This will provide themwith the depth of knowledge required to meet the needs of such users. Alternatively, personnel thathave worked in a wheelchair service in a clinical or technical role and have demonstrated strong
competence may be able to undertake such training.

8dbeZiZcXZ"WVhZYigV^c^c\
Effective training programmes will focus on developing the knowledge and skills required forclinical and technical personnel to safely and effectively fulfil their roles. A list of competences forclinical and technical personnel working in wheelchair service delivery, agreed by stakeholders,would assist in the development of consistent training programmes for these personnel. Table 4.2
provides a summary of suggested competences structured in three levels – basic, intermediate
and advanced.

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I 105

Table 4.2. Clinical and technical competences at basic, intermediate and advanced levels of wheelchair service
deliveryService delivery
level
Basic

Clinical role
Able to carry out basic user assessment,prescription, ﬁtting and follow-up forusers with basic needs (not requiring
modiﬁcations or postural support).
Able to identify and refer users who require
wheelchair modiﬁcations and postural
support; able to follow up these users once
they are provided with a wheelchair.
Able to carry out basic training in wheelchair
provision for referral network personnel.

Intermediate

Able to keep records of individual users (caseﬁles).
Able to carry out user assessment,prescription, ﬁtting and follow-up for users
requiring basic wheelchairs, wheelchairs
with modiﬁcations, and wheelchairs withpostural support.
Able to identify users who require complex
seating; able to follow up these users once
they are provided with a wheelchair.
Able to carry out training in wheelchair
provision for referral network personnel.
Able to train, supervise and support clinicalpersonnel in basic wheelchair provision.

Advanced

Technical role
Able to participate in team assessment,prescription, ﬁtting and follow-up of users withbasic needs.
Able to assemble or set up manual wheelchairs
according to the manufacturer’s instructions andprescribed components (without modiﬁcation).
Able to carry out modiﬁcations of some wheelchairor postural components as directed by thesupervisor.

Able to participate in team assessment,prescription, ﬁtting and follow-up of users requiring
basic wheelchairs, wheelchairs with modiﬁcations,and wheelchairs with postural support.
Able to assemble and set up manual wheelchairs,
including the design and production or assembly of
modiﬁcations to meet prescribed needs.
Able to carry out basic training in wheelchair
provision for referral network personnel.
Able to train, supervise and support technicalpersonnel in basic wheelchair provision.

Able to keep records of individual users (caseﬁles).
Able to lead the service team in wheelchair
provision for all users, including those withthe most complex need.

Able to carry out a full assessment of user needs,
either independently or as a member of the service
team.

Able to work with a high level ofprofessionalism, including record keeping,
service development and supervision of lessqualiﬁed personnel.

Able to identify appropriate commercial products
or to design and make custom products to meet theneeds of all users, including those with the mostcomplex needs.

Able to develop and deliver training forclinical wheelchair service personnel at alllevels.

Able to work with a high level of professionalism,
including record keeping, research anddevelopment, quality control and supervision ofservice workshop and technicians.
Able to develop and deliver training for technicalwheelchair service personnel at all levels.

4

1 0 6 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S)#'#(IgV^cZgh
IgV^c^c\egd\gVbbZYZkZadebZci
Trainers working in wheelchair service delivery require knowledge of different impairments
and chronic conditions. They need to understand who can benefit from using a wheelchair andwhich wheelchair model and features are most suitable for an individual. Also, they need a clear
understanding of how to prevent further deformities and complications, and a broad understandingof disability in general and environmental factors. Trainers also require skills in wheelchair use,
effective communication and training, and knowledge of the rights of persons with disabilities.

JhZghVcYYZa^kZgnd[igV^c^c\
Active users may effectively teach wheelchair mobility skills and transferral, demonstrating what
an actual user can do. Users may also be able to explain to trainees what it was like when they firstreceived a wheelchair, and what training or instruction they found most beneficial or would havefound most beneficial had it been available.
Box 4.5. Wheelchair service delivery training in Africa
Abdullah Munish had a spinal cord injury due to a car accident
in 2000. He was in the Kilimanjaro Christian Medical Centre in
the United Republic of Tanzania for nearly eight months. It wasa very frustrating time for him as he learnt that he would not
be able to walk again – it was almost like the end of the world
for him. From his therapists, he heard of a training opportunity
for him to become a wheelchair technologist. This gave him a
ray of hope. With the help of his therapists and supporters, hejoined the one-year Wheelchair Technologists Training Course
at the Tanzanian Training Centre for Orthopaedic Technologists(TATCOT).
The course, which is accredited by the International Society
for Prosthetics and Orthotics, teaches the technical skills ofwheelchair production as well as anatomy and physiology, thepathology of diﬀerent impairments, technical drawing, workshop management and disability studies. This enabled
Abdullah to build on his production skills and learn how to assess people and prescribe them with the right wheelchair,as well as the essential management skills needed to run a small business.
Abdullah has said of the course “I had no idea there was so much to learn about wheelchair production and distribution.
Now I can produce good quality wheelchairs, but I can also ensure that a wheelchair is right for the person using it. The
more you learn, the more you realize that the provision of wheelchairs is a complex subject and we need to continuously
develop our skills and extend our knowledge. We need more knowledge in supportive seating, for example, and tocontinuously improving our designs and our services.”
Abdullah ﬁnished the course in 2001 and was employed as a wheelchair technologist by the Kilimanjaro Christian
Medical Centre. His ﬁrst challenge was to set up a wheelchair workshop at the hospital, which took nearly a year tocomplete. Since then, he and his colleagues have been producing appropriate wheelchairs and providing services topeople living in the Kilimanjaro region. Abdullah teaches wheelchair skills and disability issues to students at TATCOT
and at a college for occupational therapists. At the Kilimanjaro Association of the Spinally Injured, he gives training toothers as a peer trainer. Abdullah has also been a guest lecturer in wheelchair design for developing countries at theMassachusetts Institute of Technology in the United States.

TRAINING

I 107)#(8djghZbdYjaZhVcYXdciZcih)#(#&8djghZbdYjaZhConsidering needs and available resources, these guidelines focus on the training of personnel
at basic and intermediate levels only. An overview of suggested course modules for personnel
involved in wheelchair services at these two levels is provided in Table 4.3. The modules for the
training, clinical and technical roles are structured in two sequential levels: basic and intermediate.
It is not necessary to provide the training in modules, but it may be more efficient to provide thesame training module to more than one group at a time.

Table 4.3. Suggested training modules for fulﬁlling diﬀerent roles in wheelchair services at basic andintermediate levels
Level
Basic

Referral network Management
1. Users,
2. Users,
wheelchairs
wheelchairs
and services forand services forreferral personnel managers

Intermediate

Role
Training

ClinicalTechnical

3. Users, wheelchairs and services - I
4. Services for
5. Services forclinicians – I
technicians
6. Health care – I
7. Training skills
8. User training – I
9. User training – II
10. Health care – II
11. Users, wheelchairs and services – II
12. Services for
13. Wheelchairclinicians – IItechnology)#(#'8djghZXdciZcih
Recommended contents of the course modules are described below. Content descriptions may
be the same in different modules, but the coverage of different modules may differ depending on
the needs of particular roles.
Trainees undertaking the intermediate level should either have completed the basic level orbe able to demonstrate full competency at that level. The recommended course content is notintended to be definitive but rather a guide for those involved in developing training packages orprogrammes. The modules and contents are not necessary taught in the order given in Table 4.3
or in the following list.

41 0 8 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G SGeneric management training (for example, personnel and budget management) and genericworkshop training (for example, tools and machinery, workshop safety, quality control and stock
management) are not included in the modules.
Module 1. Users, wheelchairs and services for referral personnel
Recommended content: users; wheelchairs; impairments; wheelchair-related health issues; general
wheelchair service provision; wheelchair provision in the trainee’s local area.
Module 2. Users, wheelchairs and services for managers
Recommended content: needs of users; wheelchairs; wheelchair service overview; wheelchair service
costing and funding; wheelchair service personnel and facilities; wheelchair service promotion;
service monitoring and evaluation; waiting list management.
Module 3. Users, wheelchairs and services
Recommended content: introduction to users; impairments; posture; introduction to wheelchairs;
introduction to cushions; introduction to wheelchair mobility; referral network; introduction toassessment, prescription, fitting, user training, follow-up, repairs and maintenance; introduction
to service evaluation.
Module 4. Services for clinicians – I
Recommended content: benefits and dangers of different postures; assessment and prescription;
fitting; follow-up; quality checking; service evaluation.
Module 5. Services for technicians
Recommended content: assessment and prescription; wheelchair assembly; fitting; follow-up; repairs
and maintenance; quality checking; service evaluation.
Module 6. Health care – I
Recommended content: health care issues, focusing on hygiene and preventing pressure sores.
Module 7. Training skills
Recommended content: presentation skills.
Module 8. User training – I
Recommended content: basic wheelchair mobility and transfers; self health care; wheelchair handlingand maintenance; adaptations to environments.
Module 9. User training – II
Recommended content: advanced wheelchair mobility and transfers.
Module 10. Health care – II
Recommended content: health care issues, focusing on care, management and rehabilitation.
Module 11. Users, wheelchairs and services – II
Recommended content: users; impairments; human anatomy; normal and abnormal postures;
wheelchair types and components; wheelchair cushions; wheelchair mobility; referral network;
training of referral personnel; methods of service evaluation.

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I 109

Module 12. Services for clinicians – II
Recommended content: prescription of cushions; evaluation of cushion performance; local referral
network; intermediate assessment, prescription, fitting, user training and follow-up for clinicians;
support and supervision of clinical personnel; how to complete clinical service evaluations.
Module 13. Wheelchair technology
Recommended content: wheelchair design; cushion modifications; construction of basic andpressure relief cushions; wheelchair preparation and modification; fabrication of postural support;intermediate assessment, prescription, fitting, user training and follow-up for technicians; support,
supervision and training of technical personnel; workshop management; how to complete technicalservice evaluations.

HjbbVgnt Effective wheelchair provision requires personnel with knowledge and skills in the provision ofwheelchairs.
t When developing training opportunities and initiatives:t TQFOEUJNFJEFOUJGZJOHTVJUBCMFDBOEJEBUFTGPSUSBJOJOHt HJWFQSFGFSFODFUPQFPQMFXJUIEJTBCJMJUJFT FTQFDJBMMZXIFFMDIBJSVTFSTXIFSFQPTTJCMF
t FYQMPSFQPTTJCJMJUJFTPGMJOLJOHXJUIFYJTUJOHSFIBCJMJUBUJPOUSBJOJOHQSPHSBNNFT
t EFWFMPQNPEVMFTBOEUSBJOJOHQBDLBHFTGPSJOUFHSBUFEPSFYDMVTJWFUSBJOJOHt FYQMPSFXBZTUPFOTVSFUSBJOJOHJTSFDPHOJ[FE BOEt CVJMEUIFDBQBDJUZPGMPDBMUSBJOFSTt Referral network personnel and those who fulfil managerial, clinical, technical and training roles
in a wheelchairs service require different types of training.

GZ[ZgZcXZh
1.

2.
3.
4.
5.
6.

Gyundi YE, Cornick C. Training: formal training; TATCOT/Motivation. In: Sheldon S, Jacobs NA, eds. Report of a Consensus
Conference on Wheelchairs for Developing Countries, Bangalore, India, 6–11 November 2006. Copenhagen, International Society
for Prosthetics and Orthotics, 2007 (http://homepage.mac.com/eaglesmoon/WheelchairCC/WheelchairReport_Jan08.pdf,
accessed 8 March 2008).
The Standard Rules on the Equalization of Opportunities for Persons with Disabilities. Rule 19. Personnel training. New York,
United Nations, 1993 (http://www.un.org/esa/socdev/enable/dissre05.htm#Rule%2019, accessed 11 March 2008).
Convention on the Rights of Persons with Disabilities. Article 4 – General obligations. New York, United Nations (http://www.
un.org/disabilities/default.asp?id=264, accessed 11 March 2008).
Best KL et al. Wheelchair skills training for community-based manual wheelchair users: a randomized controlled trial. Archivesof Physical Medicine and Rehabilitation, 2005, 86:2316–2323.
Certificate Course in Wheelchair Technology. Moshi, Tanzania Training Centre for Orthopaedic Technologists, 2007 (http://www.
tatcot.org/certificate%20WCH.htm, accessed 11 March 2008).
Sheldon S, Jacobs NA, eds. Report of a Consensus Conference on Wheelchairs for Developing Countries, Bangalore, India,
6–11 November 2006. Copenhagen, International Society for Prosthetics and Orthotics, 2007 (http://homepage.mac.com/
eaglesmoon/WheelchairCC/WheelchairReport_Jan08.pdf, accessed 8 March 2008).

4



5

EDA>8N6C9EA6CC>C<… to implement sustainable wheelchair provision.

The policy and planning guidelines:t present key activities for the planning andimplementation of wheelchair provision;t suggest strategies for costing and financing
wheelchair provision; andt suggest links between wheelchair services andother sectors.

I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

Box 5.1.

Wheelchairs changing lives …
Testimonial from a user in the P
Michelle lives on the ruraisland of Masbate, aremote area of thePhilippines. She is 20
years old, and was born
without legs and with on
one arm. Unable to propea standard wheelchair,
Michelle has lived withou
one for most of her life. F
mobility she has had to “wwith one arm and her tor
In 2005, Michelle was refecommunity workers to awheelchair service operated by aninternational nongovernmental organization.
The service team saw that for a wheelchair to be useful to Michelle, it would need to be
operable by one arm, be suitable for rough surfaces, and be easily portable on public
transport for travel into town. A local wheelchair factory that operates in partnership withthe wheelchair service team was able to create a wheelchair to these specifications.
Michelle is now able to propel herself in her wheelchair, and no longer has to moveherself along at ground level. She uses the wheelchair to attend church, make social visits
and play basketball. Most importantly, Michelle, who has a keen entrepreneurial spirit,
aims to improve the economic well-being of her family. With improved mobility, her
opportunities for this are greater.

testimonial

POLICY AND PLANNING

I 113*#&>cigdYjXi^dc
EjgedhZVcYdjiejih
The purpose of the policy and planning guidelines is to develop and implement policies for costeffective and sustainable wheelchair provision. Implementation of these guidelines will lead to:t develop a national wheelchair policy;t plan wheelchair provision programmes at national level in collaboration with all stakeholders,
based on identified needs;
t integrate wheelchair services into existing health and rehabilitation services;t develop national standards for wheelchair provision;t calculate costs and establish sources of funding; andt link wheelchair provision with existing sectors and institutions in society.

HiV`Z]daYZghVcYgZhdjgXZht Stakeholders involved in policy and planning include policy-makers, planners and implementers,

manufacturers and suppliers of wheelchairs, providers of wheelchair services, disabled people’sorganizations and users.

*#'Eda^Xn*#'#&9ZkZade^c\Veda^Xn
A national policy on wheelchair provision can ensure that users receive wheelchairs that meet
minimum requirements for safety, strength and durability and that are appropriate for theirindividual needs. A national policy can also ensure that wheelchairs are provided by trained
personnel who know how to properly assess users’ needs and how to train users and caregivers on
how to use and care for the wheelchairs.
When developing a national policy, it is recommended that the following areas are considered:t issues addressed by relevant international policies (see Section 5.2.2);t design, supply, service delivery, training and user involvement (see Section 5.2.3);
t funding (see Section 5.4); andt links with other sectors (see Section 5.5).
To avoid a separate policy for wheelchair provision, wheelchairs can be included in a general policy
for provision of assistive devices. However, specific issues related to wheelchair provision may need
to be addressed in additional policy documents.

5

1 1 4 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S*#'#'>ciZgcVi^dcVaeda^X^Zh
The two main international policy instruments related to wheelchair provision are:t the Convention on the Rights of Persons with Disabilities; andt the Standard Rules on the Equalization of Opportunities for Persons with Disabilities.

I]Z8dckZci^dc
The Convention on the Rights of Persons with Disabilities consists of 50 articles. Articles 4, 20, 26
and 32 are particularly applicable to wheelchair provision (see Box 5.2).

Box 5.2. Articles 4, 20, 26 and 32 of the Convention
Article 4. General obligations
1. States Parties undertake to ensure and promote the full realization of all human rights and fundamental freedoms
for all persons with disabilities without discrimination of any kind on the basis of disability. To this end, States Parties
undertake:(a) To adopt all appropriate legislative, administrative and other measures for the implementation of the rights
recognized in the present Convention;l(g) To undertake or promote research and development of, and to promote the availability and use of new technologies,
including information and communications technologies, mobility aids, devices and assistive technologies, suitable for
persons with disabilities, giving priority to technologies at an aﬀordable cost;(h) To provide accessible information to persons with disabilities about mobility aids, devices and assistive technologies,
including new technologies, as well as other forms of assistance, support services and facilities;(i) To promote the training of professionals and personnel working with persons with disabilities in the rights
recognized in this Convention so as to better provide the assistance and services guaranteed by those rights.
Article 20. Personal mobility
States Parties shall take eﬀective measures to ensure personal mobility with the greatest possible independence for
persons with disabilities, including by:(a) Facilitating the personal mobility of persons with disabilities in the manner and at the time of their choice, and at
aﬀordable cost;(b) Facilitating access by persons with disabilities to quality mobility aids, devices, assistive technologies and forms oflive assistance and intermediaries, including by making them available at aﬀordable cost;(c) Providing training in mobility skills to persons with disabilities and to specialist personnel working with persons withdisabilities;(d) Encouraging entities that produce mobility aids, devices and assistive technologies to take into account all aspects ofmobility for persons with disabilities.
Article 26. Habilitation and rehabilitationl
3. States Parties shall promote the availability, knowledge and use of assistive devices and technologies, designed for
persons with disabilities, as they relate to habilitation and rehabilitation.

POLICY AND PLANNING

I 115

Article 32. International cooperation
1. States Parties recognize the importance of international cooperation and its promotion, in support of nationaleﬀorts for the realization of the purpose and objectives of the present Convention, and will undertake appropriate
and eﬀective measures in this regard, between and among States and, as appropriate, in partnership with relevantinternational and regional organizations and civil society, in particular organizations of persons with disabilities. Suchmeasures could include, inter alia:l(b) Facilitating and supporting capacity-building, including through the exchange and sharing of information,
experiences, training programmes and best practices;l(d) Providing, as appropriate, technical and economic assistance, including by facilitating access to and sharing ofaccessible and assistive technologies, and through the transfer of technologies.

I]ZHiVcYVgYGjaZh
The Standard Rules on the Equalization of Opportunities for Persons with Disabilities consists of
22 rules. With regard to preconditions for equal participation, Rules 3 and 4 apply to wheelchair
provision (see Box 5.3).

Box 5.3. Rules 3 and 4 of the Standard Rules
Rule 3. Rehabilitation

Rule 4. Support services“States should ensure the provision of rehabilitation
services to people with disabilities in order for them toreach and sustain their optimum level of independence
and functioning.”“States should ensure the development and supply of
support services, including assistive devices for people
with disabilities, to assist them to increase their levelof independence in their daily living and to exercise
their rights.”

With regard to implementation measures, Rules 14, 19 and 20 are applicable (see Box 5.4).

Box 5.4. Rules 14, 19 and 20 of the Standard Rules
Rule 14. Policy-making and planning

Rule 19. Staff training

Rule 20. Monitoring and evaluation“States will ensure that disability
aspects are included in all relevant
policy-making and national
planning.”“States are responsible for
ensuring the adequate trainingof personnel, at all levels,
involved in the planning andprovision of programmes andservices concerning people withdisabilities.”“States are responsible forcontinuous monitoring andevaluation of the implementationof national programmes
and services concerning theequalization of opportunities forpeople with disabilities.”

Both the Convention and the Standard Rules clearly state that the government has the primary
responsibility for wheelchair provision. It is therefore recommended that wheelchair provision be
an integral part of national strategies.

5

1 1 6 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S*#'#(HeZX^ÒXl]ZZaX]V^gegdk^h^dc^hhjZhThere are five areas to be considered when developing a policy for basic wheelchair provision.

&#9Zh^\c
Each person has a unique set of individual or environmental needs that dictate the wheelchair
design that is best for him or her. Because user needs are so diverse, no single wheelchair design
will be appropriate for all users under all conditions. It is recommended that policies:t require that several types of wheelchair be made available to service providers to ensure thateach user receives a wheelchair that meets his or her needs; andt specify minimum national requirements to ensure that wheelchairs will be safe, durable andlocally maintainable (see Chapter 2).

'#EgdYjXi^dcVcYhjeean
Wheelchairs can be produced and acquired in a number of ways. They should be tested for strength,
durability and suitability for the context in which they will be used. Decisions will need to bemade on how wheelchairs will be produced and acquired (see Chapter 2). It is recommended thatpolicies:
t approach the overall need for wheelchairs in relation to the funding available, the sustainability ofsupply over time, local economic development, and the impact on the local wheelchair provisioninfrastructure;t encourage assessment of wheelchairs against minimum guidelines;t encourage participation of users and service providers in the selection of wheelchairs; andt take into account other national policies on related issues, such as support of local production
and local employment.

(#HZgk^XZYZa^kZgn
Providers of wheelchair services play an important role in liaising between the users and thewheelchair manufacturers. They can ensure that individual users are provided with an appropriate
wheelchair. They provide education and training about the user’s needs, as well as ongoing supportand referral to other services. It is recommended that policies:t promote user empowerment and choice (1);t require that wheelchairs be provided through a proper wheelchair service delivery system;t require that all wheelchair service providers follow recommended practices regarding ofwheelchair availability, prescription, fitting, training of users and follow-up services (see Chapter3); andt require wheelchair service providers to demonstrate transparency, fair pricing, and monitoringand evaluation of their services.

)#IgV^c^c\
Training of all personnel involved in wheelchair provision (see Chapter 4) ensures that service
delivery can be maintained at a nationally accepted level. It is recommended that policies:t encourage that training be made available for all individuals directly associated with thedevelopment and implementation of wheelchair provision, including those involved in design,
production, testing and service delivery.

POLICY AND PLANNING

I 117*#;^cVcX^c\
Each of these four areas of basic wheelchair provision requires funding. Different funding strategies
are described in Section 5.4. Typically, the costs of designing, producing and supplying a wheelchair,
the delivery of wheelchair services and training of personnel are included in the price of theprovided wheelchair, unless the costs are covered in other ways. It is recommended that policies:t specify funding mechanisms;
t set eligibility criteria for funding;t specify the categories and standards of wheelchairs and services that are funded under thescheme; andt promote user empowerment and choice.

Di]ZghjeedgibZX]Vc^hbh[dgXdch^YZgVi^dc^cVeda^Xn
Governments could also consider:t waiving import duties on raw materials used to build wheelchairs;t waiving import duties on wheelchairs if they are not available in the country;
t supporting local nongovernmental and disabled people’s organizations that provide wheelchairs
and related services through direct grants, or by facilitating relationships between local andinternational nongovernmental organizations, business communities and other stakeholders;t supporting private wheelchair manufacturing businesses through competitive tender offers,
loans and training grants;
t promoting the participation of users at every level of service planning and implementation;t removing architectural barriers to increased mobility, independence and participation, thus
stimulating interest in, use of and demand for better wheelchairs; andt including wheelchair provision and allied issues (such as accessible environments and accessible
transport) in other national policies.
Boxes 5.5 and 5.6 give examples of policies related to wheelchair provision in India and Afghanistan,
respectively.
Box 5.5. Example of a policy in India related to wheelchair provision
In India, the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act (2) was
adopted in 1995 as a result of continual lobbying by disability activists and nongovernmental organizations. This
lobbying involved extensive consultations with oﬃcials, protest marches and press conferences (3). Regarding
wheelchairs, the Act states in Chapter VII: “The appropriate Governments shall by notiﬁcation make schemes to provide
aids and appliances to persons with disabilities.”
On the basis of this Act, the Indian Government introduced the Assistance to Disabled Persons of India scheme, underwhich people with a monthly income of less than US$ 160 can get a wheelchair free of charge. If the monthly income isbetween US$ 161 and US$ 250 the user has to pay 50% of the cost, and if the income is above US$ 250, the user has topay the full cost of the wheelchair.

5

1 1 8 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

Box 5.6. Example of a policy in Afghanistan related to wheelchair provision
In October 2003, the Ministry of Martyrs and Disabled in Afghanistan published a Comprehensive National Disability
Policy. The policy was “developed in collaborative manner by all stakeholders including primarily disabled people
organizations and self help groups; disability NGOs both national and international; major line ministries including
Ministry of Education, Ministry of Public Health, Ministry of Labor and Social Aﬀairs, Ministry of Women Aﬀairs, andMinistry of Martyrs and Disabled (MMD); related UN agencies including UNOPS/CDAP, WHO, ILO, UNICEF, and UNHCR;
National Constitution Commission; and President Oﬃce” (4). It is expected that the initial policy will lead to a moredetailed and prioritized plan of action that needs to be developed in order to achieve the ultimate objectives of thispolicy. The policy goes on to state:
Provisions for people with physical disability for example, should include orthopedic rehabilitation centers;
physiotherapy services; and orthopedic, assistive and mobility devices. These services should be close to a regional orprovincial hospital with orthopedic surgical services so that the local population has easy access. They could be locatedideally, in cities with medical teaching faculties such as in Kabul, Mazar, Herat, Kandahar and Jalalabad. Future services
should provide for an expansion in orthotics as this is underserved.
All patients have the right to receive devices. Devices should be well-made, well-ﬁtting, of local materials wheneverpossible and repairable locally. Appropriate technology should be standardized throughout the country. A mechanism
for national standardization should be created with relevant experts in collaboration with MOPH [the Ministry of Public
Health].

*#(EaVcc^c\
There are six key activities in planning and implementing wheelchair provision.

&#>YZci^[n^c\i]ZcZZY[dgl]ZZaX]V^ghVcYhZgk^XZh
Identifying the need for wheelchairs is necessary to determine the numbers of services andpersonnel required and where to locate services. Such assessments also provide information on user
satisfaction with wheelchairs that are in use and may have been distributed with or without service
provision (5). Statistics should include the number of users, prevalence of different health conditions,
impairments and restrictions in participation, and the geographical location of these individuals.
Collection of data can often be facilitated by collaborating with community-based rehabilitation
programmes and disabled people’s organizations. Where collection of data is not possible, theconservative estimate that 1% of the population will require wheelchairs can be used.

'#EaVcc^c\l]ZZaX]V^gegdk^h^dcVicVi^dcVaaZkZa
It is recommended that governments be actively engaged in the planning, establishment andcontinuing development of wheelchair services. Governments are advised to consider funding
wheelchair services along with other rehabilitation services. Where government funding is alreadyallocated to wheelchair provision, it is recommended that the services be assessed to determine
whether they are being provided in accordance with the recommendations made in theseguidelines.

POLICY AND PLANNING

I 119(#:cXdjgV\^c\XdaaVWdgVi^dcWZilZZc\dkZgcbZciVaVcY
cdc\dkZgcbZciVahZgk^XZegdk^YZgh
Wherever possible, national and international nongovernmental organizations involved inwheelchair provision are encouraged to collaborate closely with relevant ministries and departments
to assist in developing and implementing the national plan for wheelchair provision. A coordinatedplan can help to make maximum use of resources and ensure that the appropriate services areaccessible to those who need them.

)#>ciZ\gVi^c\l]ZZaX]V^ghZgk^XZh^cidZm^hi^c\gZ]VW^a^iVi^dchZgk^XZhWheelchair services will be enhanced by integrating them into other rehabilitation and health careservices where possible. Integration helps to coordinate efforts among key stakeholders, makethe best use of resources such as health centres and personnel, and facilitate strong referral andconsulting networks. A good example is that of the Kilimanjaro Christian Medical Centre, wherea multidisciplinary group of medical professionals have established a wheelchair committee toaddress issues related to production, service delivery, distribution and maintenance (6).
Referral networks are critical to the sustainability of wheelchair services, and help to ensure thatthe services are accessible to those who need them. Consulting networks and access to health care
professionals such as physicians, occupational therapists, physiotherapists, speech and language
therapists and other specialists help to ensure that appropriate services and equipment are provided
to users. This is particularly important for those with complex needs.

*#6Ydei^c\cVi^dcVahiVcYVgYhd[l]ZZaX]V^gegdk^h^dc
National authorities and providers of wheelchair services are urged to develop and adopt national
standards. National standards need to address issues associated with the quality and testing ofwheelchairs, personnel training and service delivery. These guidelines may serve as a starting point
for developing standards. It is also recommended that monitoring and evaluation be carried out
to ensure wheelchair services meet the established standards.

+#:bedlZg^c\XdchjbZgh
National governments and international development agencies can create and support an enabling
environment. Users need to have the opportunity to choose the right product for themselves fromamong a variety of products. A good information package about these products, including possible
sources of funding or subsidy, could be very useful for the user in making the right decision.

5

1 2 0 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

The best strategy for developing a national wheelchair provision programme will depend on thecurrent state of wheelchair services in the country, the available resources and the needs the service
has to meet. It is useful to consider the following questions when planning wheelchair provision.
t What are the characteristics and specific needs of the user population?
t Do stakeholder groups exist and, if so, what are their interests and opinions?
t Do wheelchair services already exist (through local workshops, community-based rehabilitation,
disabled people’s organizations, other nongovernmental organizations, the private sector orgovernment)?
t Is there any wheelchair provision outside the formal infrastructure, for example provision of mass
imported wheelchairs?
t What can be done with existing resources?
t What are the current funding mechanisms?
Box 5.7 sets out various possible strategies for developing a wheelchair provision programme indifferent situations.
Box 5.7. Possible strategies for developing a wheelchair provision programme
1. The government wants to establish a national wheelchair service programme. The government may contact
interested nongovernmental and disabled people’s organizations, users, training programmes for healthprofessionals, international organizations such as WHO and the International Society for Prosthetics and Orthotics
and relevant international nongovernmental organizations to help in developing an appropriate plan for a national
wheelchair service. The government may look at its own prosthetic and orthotic services and use these as a basis
for developing a wheelchair service. It may also contact government bodies in other countries to learn from theirexperience and seek advice.
2. Wheelchair provision exists but on a small scale through independent organizations; there is no collaboration.
The government, local organizations or an international nongovernmental organization could assess the possibilityof scaling up the operation. A resource centre can be set up to involve people from the diﬀerent organizations ina collaborative eﬀort. The resource centre can then evolve into either a coalition of organizations interested inwheelchair services or an independent nongovernmental organization in its own right.
3. There are organizations in the country but no wheelchair service delivery. An interested nongovernmental
or disabled people’s organization can serve as the nucleus for a resource centre. The organization needs toidentify an appropriate organization with wheelchair provision experience as a partner (e.g. a governmental or
nongovernmental organization in a neighbouring country or an international nongovernmental organization) andshould follow the other initial steps in scenario 4 below. Alternatively, this process may be started by an international
nongovernmental organization, which then seeks out local nongovernmental and disabled people’s organizations aspartners. Eﬀorts should be made to identify and network with other countries or organizations that have had similar
experience in initiating wheelchair services.
4. There are no organizations in the country and no regular wheelchair service delivery. An international
nongovernmental organization, either on its own initiative or at the invitation of or in partnership with thegovernment, could establish a resource centre in the capital or other major city. The resource centre could be an
integral part of an already existing rehabilitation institute. The resource centre should begin by providing important
information to users, their families or caregivers and health professionals about mobility needs and wider issues
pertaining to mobility. The international nongovernmental organization should develop a stakeholder analysis andsurvey people who use or require wheelchairs, in order to identify gaps and determine the need for wheelchairs andservices. Preliminary participatory research will present options for meeting the needs. Funding should be secured to
begin wheelchair provision. Eﬀorts should be made to establish a working relationship between the resource centre
and relevant governmental bodies as a ﬁrst step in establishing a national wheelchair service.

POLICY AND PLANNING

I 121*#);jcY^c\higViZ\^Zh
An important part of setting up a wheelchair service comprises costing and establishing sourcesof funding in order to ensure the financial sustainability of the service.

*#)#&8dhi^c\
The first step towards financial sustainability is the accurate calculation of the direct and indirect
costs of wheelchair services. It is important that the cost of service delivery and the cost of the
product are accounted for. Initial costs of setting up a wheelchair service should also be provided
for but do not need to be included in the calculation of running costs. When estimating funds
needed to establish and sustain wheelchair services, planners are advised to consider the total costof wheelchair provision. The total cost is the sum of all direct and indirect costs.

9^gZXiXdhih
Productt Manufacturing cost or purchase price of wheelchairt Shipping and transportation of wheelchair
Initial servicet Personnel costs (clinical, technical, training) for assessing, ordering, fitting and trainingt Personnel costs for ordering and inventory of wheelchairst Materials and equipment for assembly and modifications
t Supplies (assessment forms, record-keeping, etc.)
Follow-up servicet Personnel costst Maintenance and repair>cY^gZXiXdhihttttManagement
Administration
Overheads
Capacity building – training of service personnel*#)#'HdjgXZhd[[jcY^c\
Many individuals who need a wheelchair cannot afford to buy one. Nevertheless, everyone who
needs a wheelchair is entitled to one, regardless of his or her ability to pay for it. Thus, funds willneed to be made available to users needing financial assistance. Different funding mechanisms
are described below.

<dkZgcbZci[jcY^c\Government funding is usually the most reliable funding source where the government iscommitted to wheelchair services. Where wheelchair services are being established or provided bynongovernmental groups, it is recommended that there be continued consultation with the relevant
government departments. Consultation should include long-term planning to determine when,
how and to what extent the government is able to assume overall responsibility for the service inthe future, including financial contributions.

5

1 2 2 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S

9dcdg[jcY^c\
In many contexts, the initiation of a wheelchair service may depend on funding from national
and international donors. Owing to its usually short-term nature, donor funding should becomplemented by advocacy for government and other more sustainable sources of funding.

L]ZZaX]V^g[jcYhbVcV\ZYWnXdbb^iiZZ
A local “wheelchair fund” may be established to subsidize the cost of wheelchairs for individual
users. Wheelchair funds exist to source funding and equitably manage donations secured forwheelchair provision. Users apply to the fund committee for a full or partial subsidy of the cost of awheelchair. It is recommended that such funds apply a means test to determine how much financial
assistance should be given. Government funding may also be channelled through a wheelchair fund.
Committees should comprise a cross-section of individuals who have a vested interest in sustainable
wheelchair provision, such as (though not limited to) users, representatives of disabled people’sorganizations, clinicians and technicians, government representatives and local dignitaries.

8dcig^Wji^dch[gdbjhZgh
Unless full government funding is provided for wheelchair purchase, it is recommended thatany financing system incorporates an element of financial contribution from users themselves.
Contribution programmes should be run in conjunction with individual means tests to ensure thatusers contribute no more and no less than they can realistically afford. Users’ contributions also
stimulate demand for products and services of appropriate quality.
A credit scheme is an option that allows users to borrow funds to purchase a wheelchair andto repay it over a period of time. Another option is an employment scheme, linking wheelchair
provision with the opportunity for the user to obtain a job or funds to start a business and to pay
for the wheelchair over time.

;ZZhdcYdcViZYdg^bedgiZYl]ZZaX]V^gh
Even when a wheelchair is donated free of charge, there are costs associated with its responsible
provision to the user, including follow-up with the user and maintenance of the wheelchair.
Organizations that import wheelchairs on a large scale without ensuring the necessary services,
as described in Chapter 3, could be required to pay a fee to support the services.

>cXdbZ\ZcZgVi^dc
Wheelchair services can be subsidized through income from the sale of other products such as
canes, crutches, walkers, and toilet and shower chairs.

KdjX]ZghnhiZb
A voucher system may enable users to make their own purchasing decisions. The user is assessed
and receives a prescription for a wheelchair with certain features. The user is given a voucher tothe value of the cheapest wheelchair that fits the user’s prescription and that also meets minimum
standards for safety, strength and durability. Users who want a more expensive chair that meetsthe prescription have to find the additional funds themselves.

POLICY AND PLANNING

I 123*#*A^c`hl^i]di]ZghZXidgh
Wheelchair service stakeholders are encouraged to collaborate with other sectors and institutions.
These linkages reduce the cost of establishing and operating a wheelchair service and allow theservice to grow more rapidly. Professionals in these other sectors will learn about wheelchair
services, while the services will benefit from the increased involvement of educated and trained
professionals. Collaboration will also facilitate more enabling or barrier-free environments, and ahigher level of inclusion and participation.

*#*#&=ZVai]hZgk^XZhVcYXdbbjc^indjigZVX]XVbeV^\ch
Existing health services provide an infrastructure into which wheelchair services can be integrated
at the lowest possible cost. Information services can be expanded to include wheelchairs, thus
facilitating the identification and follow-up of users. The advantages include a common location
for all services, the use of existing referral networks, and greater awareness among healthand rehabilitation workers. Visits by health services to outlying areas (for HIV/AIDS awareness,
community-based rehabilitation programmes and vaccination campaigns, for example), as well as
literacy, voter registration/political participation campaigns and any other outreach programmes,
also provide an opportunity to provide wheelchair services.

*#*#':YjXVi^dc
Linking wheelchair provision with the education sector can facilitate the development of training
materials and implementation of training programmes. In some instances, core subjects may alreadyexist within the academic institution. In these situations it may be possible to integrate training
for wheelchair provision into existing courses. Similarly, manufacturing and testing laboratories
may exist, which can help facilitate the design, production and testing of wheelchairs. University
students in a variety of technical and health disciplines can be recruited for careers in wheelchair
provision. Service providers can engage students for field placements to obtain experience. Finally,
academic institutions will be familiar with methods of accreditation, which may help in establishingnationally recognized, accredited training for wheelchair provision.
Wheelchair services can also work with the education sector to ensure education is accessible topeople with disabilities, as stated in Article 9a of the United Nations Convention on the Rights of
Persons with Disabilities. With a wheelchair and a barrier-free environment, a person with disability
can access education in school or college. Schools and colleges need to have, as a minimum, easy
access to classrooms, wide doorways and accessible toilets.

5

1 2 4 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S*#*#(A^kZa^]ddY
It is likely that new wheelchair users will need help in finding a job or acquiring the necessary skills
to find a job or return to work. Article 27 of the United Nations Convention states:
Parties recognize the right of persons withdisabilities to work, on an equal basis with others;
this includes the right to the opportunity to gaina living by work freely chosen or accepted in alabour market and work environment that isopen, inclusive and accessible to persons withdisabilities.

Fig. 5.1. Living with dignity

Policies that encourage employment training,job referral programmes and mainstream
education for people with disabilities can help
to increase the employment opportunities forusers. There are benefits for both users andsociety when users are able to secure their own
livelihood. Through employment, users andtheir families can better secure the necessities
of life and improve their economic and social
situation (see Fig. 5.1.).
The Standard Rules on the Equalization of Opportunities for Persons with Disabilities notes thatusers have obligations as well as rights. With mobility, and a greater opportunity for work, users
are in a better position to fulfil their obligations to society.

*#*#)HdX^Va
With a wheelchair and a barrier-free environment,a person with disability can easily participate
with dignity in social and community life. Active
participation in the social, spiritual and cultural
life of a community has a strong impact on thequality of users’ lives and their self-perception
and self-esteem. Both participation in andappreciation of the arts, sports and recreational
activities, can greatly contribute to a positive
self-image and well-being (see Fig. 5.2.).

Fig. 5.2. Good quality of life

POLICY AND PLANNING

Barriers to participation of users include negative
attitudes held by the public, the users’ families andsometimes the users themselves. An effective way ofovercoming attitudinal barriers is for users to become
more visible, demonstrating to family, friends andthe broader public that they can participate in social
activities (see Fig. 5.3.). Through direct experience,
users and those around them learn the full extent
of a user’s abilities. Users have the same rights andopportunities as others to have a family. In fact, awheelchair makes family life easier and less stressful
for a person with disability and his or her family.

I 125

Fig. 5.3. Active participation

Governments are encouraged to assist users inaccessing wheelchairs and services that allow themto function as independently as possible. Users andtheir families also need to receive the social benefits
to which they are entitled.

*#*#*>c[gVhigjXijgZBarrier-free environments create opportunities for users to exercise their rights, opportunities andfreedoms, to become productive members of the family and to fulfil their duties to their family andcommunity. The success and optimization of wheelchair provision in any country largely depend on
the environment: a barrier-free environment will benefit not only wheelchair users but also others,
especially older people. Basic aspects of the infrastructure that need to be accessible include:t buildings, i.e. housing and public buildings providing, for example, health services, education,
employment, banking, government services and other public services;t public transport, such as buses, trains and ferries;t roads, streets and footpaths;
t food, water and sanitation facilities such as open-air restaurants and markets, water taps, tube
wells and toilets; andt facilities for culture and recreation, for example stadiums, cinemas, theatres, parks, public halls
and community centres.
It is recommended that experts on wheelchair accessibility, for example users with adequate
knowledge, be represented on local, regional and national committees that determine planningand construction. Universal design, including wheelchair access, could be included as a requirementin university programmes for civil engineering, architecture, urban planning and design.
Box 5.8. Access for all in Sri Lanka
In Sri Lanka, a consortium of disability organizations was formed to support a campaign to promote the inclusion andparticipation of all people with disabilities in tsunami relief, reconstruction and development work. The Access for
all campaign asks for the inclusion of people with disabilities when rebuilding the nation. This means rebuilding anaccessible nation: making all public buildings, transport, places of employment, services and infrastructure accessible
to all. It also means including people with disabilities in plans for the nation.

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1 2 6 I G U I D E L I N E S O N T H E P R O V I S I O N O F M A N U A L W H E E LC H A I R S I N L E S S R E S O U R C E D S E T T I N G S*#+>cXajh^dcVcYeVgi^X^eVi^dc
The ultimate aim of wheelchair provision is to facilitate inclusion and participation. Mobility is often
a precondition for participation in society. Hence, provision of wheelchairs that enhance personal
mobility is an essential element of interventions to ensure that all citizens of a country get equal
opportunities to enjoy all human rights and fundamental freedoms.
Inclusion and participation of people using wheelchairs will require:t barrier-free environments and disabled-friendly products and services;t general services and systems such as housing, health care, transportation, schools and incomegenerating activities are made accessible; andt specific services and systems such as medical treatment, rehabilitation, wheelchairs and otherassistive devices and support services are made accessible and affordable (7).
It is important that all stakeholders in wheelchair provision are aware of and understand the ultimate
aim of providing wheelchairs, and translate this understanding into appropriate action to ensuresustainable inclusion and participation. When the wheelchair needs of people in less-resourced
settings begin to be met, this will benefit not only the individuals and their families but also theircountries.

HjbbVgnt Countries have the primary responsibility for wheelchair provision, as stated in United Nations

policy instruments.
t Areas to consider when developing a policy for wheelchair provision include design, production
and supply, service delivery, training and financing.
t Key activities in planning and implementation wheelchair provision are:t JEFOUJöDBUJPOPGOFFETt QMBOOJOHBUOBUJPOBMMFWFMt DPMMBCPSBUJPOBNPOHTUBLFIPMEFSTt JOUFHSBUJPOPGXIFFMDIBJSTFSWJDFTJOFYJTUJOHIFBMUIDBSFPSSFIBCJMJUBUJPOTFSWJDFTt BEPQUJPOPGOBUJPOBMTUBOEBSETt FNQPXFSNFOUPGVTFST
t Linking wheelchair provision to other sectors of the society can be effective.
t Infrastructure and transport systems need to be accessible to all.
t The ultimate aim of wheelchair provision is to facilitate inclusion and participation.

POLICY AND PLANNINGI 127

GZ[ZgZcXZh
1.
2.
3.
4.
5.

6.

7.

Scherer MJ. The change in emphasis from people to person: introduction to the special issue on assistive technology. Disability& Rehabilitation, 2002, 24:1–4.
The Persons with Disabilities (Equal Opportunities, Protection of Rights & Full Participation) Act, 1995. New Delhi, Ministry ofSocial Justice and Empowerment, 1995 (http://socialjustice.nic.in/disabled/welcome.htm, accessed 11 March 2008).
Wong-Hernandez l. Moving legislation into action: the examples of India & South Africa. Disability World, 2001, No. 6 (http://
www.disabilityworld.org/01-02_01/gov/legislation.htm, accessed 11 March 2008).
The Comprehensive National Disability Policy in Afghanistan. Kabul, Ministry of Martyrs and Disabled, 2003 (http://www.
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5

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