Individual: Barriers can be related to age, gender, type and extent of mobility impairment, living environment, socioeconomic and education status (86).

Stigma: Cultural beliefs and stigma surrounding wheelchair use can discourage those in need from accessing wheelchair services, weakening demand (87).

Information: Wheelchair users and their families lack information about appropriate wheelchairs and the benefits of wheelchair services, and are therefore not empowered to demand appropriate wheelchairs through wheelchair service delivery models.

Participation: A lack of representation from different groups of wheelchair users limits equitable planning and delivery of these services.

Policy: Absence of policies and national wheelchair provision planning, and/or existing policies that cause restrictions, for example limiting funding or product ranges (88).

Data: Limited data regarding the need for wheelchair provision (89) hampers demand.

Priorities: Medical models of disability have prioritized restoration of walking over optimized mobility, contributing to gatekeeping of access to wheelchair provision (90).

Funding: Insufficient funding within systems for personnel, products, equipment, spares, consumables, maintenance and repairs required for wheelchair provision (91).

Funding mechanisms: Complex funding mechanisms, often with built-in restrictions such as price and/or feature caps, or which environments are considered medically necessary, are difficult for wheelchair users and service providers to navigate (92).

Affordability: Even low-cost appropriate wheelchairs may be unaffordable within public funding schemes and/or for individual wheelchair users (63,93).³

Distribution: Barriers to product distribution within a country limit access and choice (e.g. shipping, contracts with distributors, supply chain access).

Design: A limited number of appropriate and affordable wheelchairs limits choice, and ability to meet the diversity of wheelchair users’ needs including their different physical environments.

Inequity: The global market is driven by high-income country market demand and funding. Many leading global wheelchair manufacturers do not focus on low- and middle-income countries due to limited public funding for procurement and provision of wheelchairs in these countries (94).

Regulatory: Payment policies and burdensome bureaucracy acts as a disincentive for wheelchair producers to bring new models to established markets or existing models to new markets. Absence of national product standards and/or lack of legislation requiring such standards, or excessively high product standards for safety, effectiveness and efficacy to get approval for distribution, contribute to regulatory barriers.

Information: Limited clear and unbiased information for personnel and wheelchair users impedes informed decisions to select the most appropriate product.

Awareness: Purpose and value of wheelchairs and wheelchair services is not widely understood by key stakeholders, leading to distribution of poor quality, inappropriate wheelchairs outside of a wheelchair service model (14).

Operating in silos: Wheelchair programmes functioning independently from national health systems (95), often not staffed by trained service providers, leading to confusion, lack of ongoing support for wheelchair users, as well as wasted resources.

Fragmentation: Weak referral networks and links between wheelchair service delivery steps result in many people’s needs not being met in a timely manner (if at all).

Access: Many people are unable to access wheelchairs through wheelchair services (especially centre-based models) due to distance, limited accessible public transport and costs, and economics of accommodating disability in a family income.

Timeliness: Low capacity, bureaucracy and lack of funding leads to long wait periods for new wheelchair users, and/or follow-up support (e.g. training and repairs) (96)

Waste: A lack of systems to maintain and repair wheelchairs result in wheelchair abandonment and/or shortened wheelchair lifespans; while an absence of systems to refurbish and recycle wheelchairs and/or spare parts results in wasted resources.

Follow up: Lack of follow up puts wheelchair users at risk of health consequences and wheelchair breakdown.

Quality: Limited and inconsistent training programmes for wheelchair service personnel, particularly at the national level (21), limits quality wheelchair provision.

Quantity: An inadequate number of appropriately trained personnel, exacerbated by training being limited to higher level professionals, whereas involvement of mid-level and community-level personnel could expand the workforce who are able to deliver identification, referral and service steps (97,98).

Competencies: Entry-level competencies for clinically trained personnel providing wheelchair services often do not exist (99), resulting in low and untested competencies.