Designing Inexpensive and Durable Prosthetics for the Developing

World: A Review
Michael Porter, Max Greenberg, Chris Hemmerich, Jung Kim, Venkatesh Raman
BME 401, Penn State University, Department of Biomedical Engineering
AbstractThere is a rapidly increasing need for
prosthetic devices in developing countries. While
the functionality of devices designed for advanced
countries can alleviate some of the problem, it is not
a good long-term solution. There are several
barriers to the successful implementation of western
devices into developing countries. Prosthetics in
developing countries need to be both cost effective
and durable. Equally important to the functionality
of the device, are the cultural and aesthetic
concerns. Both of which, must be considered in the
design and the implementation of a prosthetic
device in developing countries.

Background
The purpose of a prosthetic is the same across all
countries and language barriers, to restore and
maintain a patients most value possessions their
health and well-being. However, other important
considerations in the design and implementation of
a prosthetic device are the culture where the
prosthetic is being introduced, and the overall
cosmetic appearance of the device itself.1
The design of any prosthetic can be classified by
having three major components: the socket, the
extension, and the artificial appendage. The socket
serves as the interface between the device and the
amputated limb. The extension replaces the length
of the lost limb. The appendage attempts to replace
either the hand or the foot that was lost.2
From this, one would think that designing a
prosthetic device would be a universal pursuit,
being that a device in a first-world country and a
device in a third-world country would be designed
the same. In fact, just the opposite is true. There are
several factors other than the functionality of the
device that can affect the overall usability and
desire of the patient to use the device on a regular
basis. Some of the chief concerns that are unique to
the developing world are the availability of
valuable resources and the access to health care

personnel.1 These factors make designing a

prosthetic for a third world country a challenging
task. In this review, several different factors will be
analyzed and considered in the design and
implementation of prosthetic devices in
developing countries.

Physiological Basis
Rapid Increase in the Amount of Amputees
The rate at which the upper-limb amputee
population is growing in developing countries is
exceedingly high. For example, in India alone, it is
estimated that 17,000 new patients will require a
prosthetic device each year. However, India is not
alone in its demand for prosthetic devices. While
disease, auto accidents, congenital defects, and
firearms are all sources of amputation, the most
common causes of amputation are farm accidents
and war in developing countries.3
Citizens in countries that are in civil war are
often at risk of becoming an amputee due to
combat, land mines, and war atrocities. Civilians in
war zones are often left without medical
infrastructure or first aid.4 One documented case of
war atrocities was in Sierra Leone, where hundreds
of civilians had their hands amputated during the
countrys civil war due to political reasons. In
other countries, military and political unrest has
shown similar results. It is estimated that there is
around 1 amputee for every 650 citizens in
Afghanistan, 1 per 350 in Angola, and 1 per 400 in
Cambodia. Juxtaposed with 1 per 22,000 in the
United States demonstrates that his is clearly an
epidemic in developing countries, especially those
experiencing either political or civil unrest.3 In fact,
there have been more people injured or killed by
land mines than both of the atomic bombs dropped
on Hiroshima and Nagasaki combined in the
second half of the twentieth century.2

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Current Approaches
At the time of writing this review, there existed
few novel solutions to the problem of prosthetics in
developing countries. The standard approach to the
current problem is to implement technology that
already exists in technologically advanced
countries to these underserved countries. These
devices are extensive and each individual device
will not be described in detail in this review. As
discussed in the other parts of this review, this
strategy is not an ideal solution. Moreover, it is
insufficient for the reasons of cost, durability, and
lack of resources in these countries.
Materials
When designing devices for developing
countries, it is very important to consider what
material is being used to construct the device. For
example, materials such as wood, metal, and cloth
are commonly used in current designs. However,
these are not ideal because they are highly
susceptible to the harsh, humid environments that
are present in these areas. This is an important
consideration in countries where wading in water
is not only common, but is a daily occurrence for
many of the citizens.
Cyborg Beast
Recently, some engineers have begun to
consider 3D printing as a solution for low cost,
durable prosthetics. One such device, named the
Cyborg Beast is designed for use in children
because it can produce a prosthetic hand for a low
cost. The material choice for the device is
polylactic acid (PLA) because it is not only easy to
3D print, but is also a rugged material.5 It is also
biodegradable, which is an important consideration
in the choice of material in order to reduce the
overall carbon footprint and environmental impact
of the device.

Challenges to Alleviating Problem

Barriers for Implementation of Existing
Technology in Developing Countries
While there are many upper-limb prosthetics that
have been developed in technologically advanced

countries, it is a very difficult task to implement

these devices in developing countries. The
overriding problem in the majority of developing
countries is the lack of funds available for
healthcare services. However, when there are
funds available, cultural considerations may
prevent developed technology to be successful in
developing countries. 1
One of the largest obstacles for the
implementation of medical devices for these
countries is the lack of trained medical personnel.
Beyond physically delivering the device to the user,
there are several other obstacles to provide
amputees the devices they need. Due to the nature
of the problem, there needs to be a degree of
personalized
healthcare
for
the
proper
implementation of the device. Each prosthetic
device needs to be properly fitted, aligned, and
adjusted by health care professionals before it can
properly be used. The World Health Organization
currently estimates that there is a deficit of
approximately 40,000 technicians. Moreover, they
also estimate that it would take over 50 years to
train just 18,000 more skilled technicians.6
Need for a Rugged Design
Although prosthetics are expensive, they are
necessary for patients in developing countries to be
able to work and earn a wage.3 Many developing
countries rely on an agricultural economy. This
requires the majority of citizens in these countries
to earn a living by doing manual labor, rather than
less strenuous and demanding tasks like office
work.2 Because most of the devices that currently
exist were designed for light use in developing
countries, these devices often do not last very long
in the hot climate where the devices are being
implemented. The exposure of these devices to dirt
and water can quickly wear down a device to a
point where it is no longer usable.3 In fact, a
conventional limb that is constructed from wood
and resin only has a life of 18 months in these
climates. This presents a major problem for users
of the device, who rely on the technology to do
their daily tasks.2

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Economic Impacts and Cost of Prosthetics

Conventional prosthetic devices are also very
expensive and many workers in developing
countries cannot afford to buy them. Many of the
workers in developing countries rely on manual
labor to support their families. When large portions
of the labor force can no longer work, it puts a
large strain on the economy of the country. The
nation will subsequently experience decreased
productivity and slowed economic development.
An amputee who does not have access to
prosthetics is at a severe disadvantage in a labor
force. Some of the least fortunate may even be
forced to beg to help them provide for their
families.3
In the United States, a body-powered upper-limb
prosthetic can cost more than $15,000. However,
even prosthetics that are made through aid
organizations such as the International Committee
of the Red Cross, can cost over $1,000 to produce
and properly fit and adjust.3 Prosthetics that are
made in the developing countries can possibly be a
little less expensive. It is estimated that these
devices can cost anywhere between $125 to $1,825,
depending on the country and the manufacturer.
This is a major problem because even though these
devices are cheaper, their lifetime cost can be in
the thousands of dollars due to maintenance, which
is very expensive for families in these countries
who live in rural areas, who live off $300 a year. It
can take years for a family to be able to afford one
prosthetic, let alone the maintenance and
replacements that can be needed as the device
wears out.2
Children who need prosthetics are at an even
larger disadvantage. Because they are constantly
growing, they will require many different
prosthetics before they reach adulthood, there is an
even larger burden on their families. Children
between the ages of 4 and 16 usually grow around
three-quarters of an inch each year. Because of this
growth, a new prosthetic is typically needed every
6 months to 1 year for a children, in comparison to
3 to 5 years for an adult.2

Cultural Considerations
It is very important to consider the culture to
which a device is being implemented. For example,
in many hot and humid environments, it is very
common for people to walk barefoot or with open
toed sandals. Commonly, footwear is removed
when entering a place of worship in these countries.
As a result, it is very important that foot prosthetics
in these regions are aesthetically acceptable so that
the user will feel comfortable about displaying
their device in public. One device, the Jaipur foot
addresses these concerns with a removable heel
that simulates taking off ones footwear. It is also
designed so that the user can sit cross-legged,
which is a practice that would be important in both
worship and in the culture. This device also allows
for users to climb trees, which is commonly done
in these regions to collect fruit to eat.1
Another consideration is cultures where it is
customary for younger citizens to genuflect or
kneel before their elders. People who fail to do this
would be considered disrespectful and it may even
be taken as an insult. When designing a device for
users in this country, biomedical engineers need to
enable a user of this device to be able to do this
easily.1
In very poor rural areas, everyone in the village
must work so that the village has enough food to
survive. Unfortunately, people who cannot work
are considered a burden to both their family and the
community as a whole. In cities, however, an
amputee may be seen as a burden because they are
taking work away from an able-bodied person,
who is believed to be able to do the task in a more
efficient manner. Amputees are given very little
consideration and there are not many opportunities
for rehabilitation. Many of the misconceptions
directed toward amputees stem from old traditions
and a lack of knowledge. Some humanitarian
groups are striving to help to clear up these
misconceptions and give amputees a chance to
work. It has been reported that there has been
progress in changing the attitudes of both the
able-bodied individuals and the amputees alike.4

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Rehabilitation
Equally important to the device itself, is the
rehabilitation of the user who receives such a
device. Although it will not be discussed in detail,
the rehabilitation process ideally begins as soon as
possible. Before, the patient even receives the
device, the patient needs to do pre-prosthetic
rehabilitation, which consists of activities such as
strengthening the muscles in their residual limb.
Once the patient is introduced to the prosthetic,
they should undergo more rehabilitation and
training with their specific device. The fit of the
device is of the utmost importance as well as the
overall comfort of the device. Ideally, the amputee
would then train with a health care professional in
order to become more accustomed to doing daily
tasks with their new device. However, as discussed,
it remains a challenge to provide enough workers
in developing countries.6

should work alongside other groups to help and

direct policy decisions that will eventually lead to a
better dispersion of their products to the people
that need them. In this manner, engineers will be
able to ensure that the products that are not going
to waste because they are not reaching the people
for whom they are intended.

Opportunities for Engineering Solutions

References

There are many opportunities for biomedical

engineers to help solve the problem presented in
this review. One such way, as discussed, is the
Cyborg Hand, which is a 3D printed hand that is
thought to be both durable and cost effective.
Engineers can try to build off advances such as
these in order to improve their designs and also to
try to extend their use to areas such as artificial legs
as well.
In addition, there is also a great opportunity for
engineers to develop new materials that can be
printed using 3D printing technology, which are
both cost effective, provide superior structural
support, and are good for the environment. Better
materials that are developed to be both cost
effective and durable can also be implemented to
existing devices to increase the usability of already
established solutions. By doing this, engineers will
have access to the many devices that already exist,
and modify them so that they are more suitable for
the hot climate where these devices have the
greatest need.
A third area where engineers can help to develop
design solutions is in the implementation of the
devices to the developing countries. Engineers

Conclusion
There is a large demand for prosthetics that are
both cost effective and durable. However, when
implementing these devices, the cultural of the
population should also be taken into consideration
so that the device will be in accord with the mores
of the people. Many important considerations must
be made when designing any medical device, such
as the materials. In addition, healthcare
infrastructure needs to be developed in these
countries to implement existing technology and to
develop new technologies for amputees.

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Zuniga, J. et al. Cyborg beast: a low-cost

3d-printed prosthetic hand for children with
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