An Exploration of Lower Limb Prosthetics Service Delivery in Namibia in Comparison to Global Standards

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Background: In 2017, the World Health Organisation published prosthetics and orthotics standards that are aimed at improving prosthetics and orthotics services internationally. The standards are meant to assist member states to improve prosthetics service delivery. The prosthetics standards document calls for the comparison of “the national prosthetics systems and services with the complete set of standards to derive a baseline against which to monitor further development” (WHO, 2017: xxi). Aim: The aim of this study was to explore the status of lower limb prosthetics service delivery in the public healthcare system of Namibia and compare it against the World Health Organisation`s global standards for prosthetics and orthotics. Methods: A sequential mixed methods design was adopted for this study where qualitative (descriptive) and quantitative (cross-sectional survey) data were collected and analysed sequentially. The study was carried out in Namibia's Khomas (urban) and Oshana (rural) regions. Insufficient records necessitated non-probability sampling in both settings and phases. Qualitative data were collected through semi-structured interviews with two service managers, nine service providers, and 16 prosthetics service users guided by interview schedules. Quantitative data were collected from two service managers, ten service providers, and 120 lower limb prosthetics service users. A survey was developed for managers and providers while users completed the TAPES-R. Content analysis was used for the qualitative data. The 60 standards provided deductive themes. Quantitative data was mainly analysed descriptively. Data from the two phases was triangulated and presented together. Findings: Findings showed that 12 of the 60 standards were implemented in Namibia. A further 28 were partially adhered to, while 20 were not implemented at all. Namibia had national policies that guide prosthetic service delivery, but the policies were outdated and not well adhered to. The study established that funding was available but insufficient. There was a wide range of prosthetics products available at no cost to users. Users’ needs were mostly met by available prosthetic products except for the ability to perform vigorous activities and participate in sports, which were limited for 90.8% (n=109) and 87.5% (n=105) of users respectively. Service users 82.6% (n=99) were satisfied with their prosthetic devices and the prostheses allowed them to be economically active 75.0% (n=90). Service providers were well-trained but did not regularly participate in continuous professional development. Training to qualify as a prosthetics service provider was not available in Namibia and in-service training opportunities were scarce. The number of service providers was insufficient. Lower limb prosthetics services were provided to all in need but often this involved long travel distances (mean 258.38 km; sd 265.611) as services at the primary level were not readily available. Users were not involved in policy development and implementation. Experienced users had the choice of products and providers, but first-time users did not. Users were provided with training, follow-up, and repairs. There was little collaboration with other team members during prosthetic rehabilitation. Conclusion: The study showed that more efforts are needed toward improving the delivery of lower limb prosthetics services in Namibia and upgrading them to levels that are in accordance with the World Health Organisation standards. It was concluded that a systems approach, based on the ten ‘Ps’ of systems thinking in assistive technology, could be adopted as a conceptual framework to identify interventions that can be most effective and efficient in efforts to meet the required standards.
Centre for Rehabilitation Studies