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15 (2022) 200094
Available online 9 June 2022
2667-3789/© 2022 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
Design of an assessment tool for implementing assistive technology (AT)
reuse programs in France
Isabelle Barbet
a
,
*
, Laurence Hartmann
b
,
*
, Diane Deville
c
,
1
, Marie-Sophie Ferreira
c
,
2
a
Conservatoire national des arts et m´
etiers de Paris (CNAM), CEDRIC EA4629, 292 Rue Saint Martin, Paris, 75003, France
b
Conservatoire national des arts et m´
etiers de Paris (CNAM), LIRSA EA4603, 292 Rue Saint Martin, Paris, 75003, France
c
Alcimed France, 57 boulevard de Montmorency, Paris, 75016, France
ARTICLE INFO
Keywords:
Assistive technology reuse
Waste management
Prevention programs
Circular economy
Matrix scorecard
ABSTRACT
Assistive technologies (AT) are essential in the daily life of elderly and people with disabilities. However, a
growing demand for AT around the world remains unmet. The second-hand market has the potential to meet
some of these unmet needs while reducing the amount of AT disposed of in landlls. The French government has
recently engaged in nancially supporting AT reuse programs. The current research aims at developing frame-
work tools for project initiators. It was based on the literature on waste management and AT reuse and on a
detailed analysis of seven innovative French local AT reused programs. Using a qualitative approach, the work
resulted in an evaluation grid and a matrix scorecard of indicators for the management of future AT reuse
programs. The aim of this tool is to consolidate the development of AT reuse programs to promote their access to
people with disabilities while reducing waste production.
1. Introduction
WHO (2019a) recently estimated that over one billion people require
one or more assistive technologies (ATs) including durable medical
equipment (i.e., medical beds, hearing aids, wheelchairs, communica-
tion aids, walking aids, special computer keyboards, speech generating
devices, etc.) which are an essential support to elderly or people with
disabilities’ daily living, social participation and quality of life. This
number is expected to increase to over two billion by 2050 (World
Health Organization, 2019a) due to the ever-increasing prevalence of
non-communicable diseases associated with an aging population (Li Pi
Shan et al., 2012). There are unmet needs, a growing demand for AT and
a pool of abandoned or unused ATs. Such mismatch must be urgently
addressed by public health and environmental policies for resource
management and recycling as used ATs will eventually be disposed of as
landll waste (Sousa et al., 2021). Many countries are exploring the
potential for AT reuse as a solution to reduce environmental and
healthcare costs and increase availability (Cohen and Perling, 2015;
Kniskern et al., 2008; Li Pi Shan et al., 2012; Ordway et al., 2018;
Pitonyak, 2018; Sousa et al., 2021; Sund, 2017; Verbrugghe et al., 2015;
Vincent et al., 2003; Wright, 2012).
In France, ATs are in most cases purchased new since the French
health insurance system does not cover second-hand devices, except,
since 2020, for some types of wheelchairs. This state of affair discour-
ages any second-hand market and the recycling of devices (Denorman-
die and Chevalier, 2020). At the same time, there is no systematic
procedure for recycling ATs that are no longer in us. In some regions and
for specic groups (e.g., people with visual impairments, amyotrophic
lateral sclerosis, certain motor impairments), there are associations that
collect and distribute second-hand ATs with the dual objective of both
(1) supporting people by improving matching between their needs and
devices and by shortening acquisition time and (2) controlling the
consumption of raw materials, but these are not widespread. In recent
years, in connection with a 2015 call for projects to fund a new AT reuse
programs by the CNSA (‘Caisse Nationale de Solidarit´
e pour l’Autono-
mie’
3
), new programs from the third sector have emerged. These pro-
grams offer refurbished ATs that extend their lifespan while maintaining
their original performance.
* Corresponding authors.
E-mail addresses: isabelle.barbet@lecnam.net (I. Barbet), laurence.hartmann@lecnam.net (L. Hartmann).
1
Current address: Alcimed GmbH, Konrad-Adenauer Ufer 79–81, 50668 Cologne, Germany
2
Current address: Agence Nationale d’Appui `
a la Performance des ´
Etablissements de sant´
e et m´
edico-sociaux (ANAP), 23 Av. d’Italie, 75013 Paris, France
3
CNSA : French social security agency, under the Ministry of Solidarity and Health authority, responsible for providing nancial support and funding in-kind
assistance services to people with loss of autonomy, whether due to inrmity, old age and/or disability)
Contents lists available at ScienceDirect
Resources, Conservation & Recycling Advances
journal homepage: www.sciencedirect.com/journal/
Resources-Conservation-and-Recycling-Advances
https://doi.org/10.1016/j.rcradv.2022.200094
Received 10 February 2022; Received in revised form 26 May 2022; Accepted 3 June 2022
Resources, Conservation & Recycling Advances 15 (2022) 200094
2
The present research aims to design a framework tool to support
initiatives for the development of sustainable activities related to AT
reuse programs. This framework tool is expected to foster the develop-
ment of innovative practices in France combining a reasoned manage-
ment of AT resources and the partial recovery of people with disabilities’
needs. It also aims to identify good practices and risk factors for the
sustainability of projects, to develop quality indicators and to recom-
mend decision-making guidelines for project leaders. The tool presented
in the appendix of this paper was developed using an iterative approach
consisting of three main stages. At the rst stage, we developed a process
evaluation framework including the denition of objectives following
the French approach of “modernization of public action”, that is the
main eld of public policies which consists of assessing the different
steps of a program’s value chain. We built indicators following pub-
lished practices developed in other countries, as well as practices
developed in France (bottom-up approach based on an exploratory
study). We conducted a review of the literature presented in Section 2
and the methodology used in Section 3. At the second stage, we con-
ducted a qualitative analysis of the French programs following our
guidelines, identied levers and obstacles impeding their implementa-
tion and assessed the ease of use of our guidelines. Main trends are
presented in Section 4 as key lessons from the cross-sectional analysis. At
the third stage, we built a balance scorecard following a top-down
approach as an operational dashboard for stakeholders and/or donors.
2. Assistive technology reuse programs in the literature
Most of the scientic literature on AT reuse programs originates from
countries where national legislation or guidelines on AT reuse exist (e.g.,
the United States, Quebec, the Netherlands, the Nordic countries). Much
of this literature focuses on the recycling of mobility aids (Lau et al.,
2008; Li Pi Shan et al., 2012; Rarrbo, 2010; Vincent, 2000; Vincent et al.,
2003; Wilcox et al., 2013) and medical devices (Ordway, 2016; Ordway
et al., 2018; Pitonyak, 2018; Wright, 2012). The existing research aims
to contribute to the independence and quality of life of people with
disabilities or the elderly while considering the: 1) the socioeconomic
benets of making more devices available and less expensive as needs
increase; reducing healthcare costs through the availability of used de-
vices; and controlling the quality of technical assistance services
rendered to individuals; and 2) the environmental benets of reducing
the number of devices being discarded as landll waste.
2.1. Socioeconomic benets
The WHO Global Collaboration on Assistive Technology (GATE)
denes assistive technologies (ATs) as “products and related services
used by persons with disability to enable and enhance their inclusion in
all domains of participation” (de Witte et al., 2018, p 467). Some AT are
simple and low-tech while others are very expensive and complex de-
vices. The diversity of AT users and the wide range of AT solutions make
their allocation and the monitoring of their use a complex area of ser-
vices delivery. The aspirations and individual characteristics of the user
complexify the acceptability and use of a particular AT (AAATE and
EASTIN, 2012; Andrich et al., 2013; Federici and Scherer, 2018; World
Health Organization, 2019a).
Adapted AT (Federici and Scherer, 2018) translate into substantial
gains in autonomy and independence for elderly and people with dis-
abilities and their families, enabling them to lead dignied and inde-
pendent lives (Agree, 2014; Boucher, 2018; de Witte et al., 2018;
Gowran et al., 2020; MacLachlan et al., 2018). In addition, the use of an
AT brings socioeconomic benets by reducing direct health and social
support costs, and by improving individuals’ access to work, which
indirectly stimulates economic growth (Rohwerder, 2018; World Health
Organization, 2019a). Unt AT may not be used and may be discarded.
Existing literature shows that, in Western countries, AT abandonment
rate is estimated to be one third after one year (Dijcks et al., 2006;
Federici et al., 2016a). Wheelchairs represent an exception with an
abandonment rate around 5% (Samuelsson and Wressle, 2008). Much of
the scientic community (Demers et al., 2002, Demers et al., 2016;
Desideri et al., 2014; Dijcks et al., 2006; Federici et al., 2016b; Gowran
et al., 2020; McCreadie and Tinker, 2005; Phillips and Zhao, 1993;
Scherer and Federici, 2015; Wanet-Defalque and Machab´
ee, 2009)
agrees that AT abandonment is the result of a complex interaction be-
tween four main factors: (1) individual factors (age, gender, diagnosis,
self-expectations, social group expectations, acceptance of impairment,
emotional maturity/internal motivation, disability progression, severity
of disability, change in severity of disability, use of multiple devices); (2)
assistive device factors (quality of the device, appearance of the device);
(3) factors related to the environment of use (social group support,
physical obstacles, presence of opportunities, market procedures for
devices); (4) factors related to professional intervention (consideration
of users’ opinions, instruction and training, correct provisioning process
and installation, length of delivery period, service follow-up).
AT abandonment represents a waste of 5 to 30% of their cost of
acquisition which can represent signicant amounts for funders (Fed-
erici et al., 2016a). Thus, many authors suggest that abandoned ATs
could be sell at a lower cost by another person with similar needs
(Gowran et al., 2020; Kniskern et al., 2008; Walsh et al., 2015). It is
expected that promoting AT reuse programs will reduce difculty of
access. Currently, only 10% of people who need ATs have access to them
worldwide (World Health Organization, 2016). According to WHO, this
is due to their high cost, limited availability, inadequate funding in
many regions, a very signicant lack of awareness of the possibilities for
gaining autonomy through their use, and nally a lack of adequate
training for professionals. Barriers related to the price of ATs and
obtaining funding are frequently cited (Cohen and Perling, 2015;
Hammel and Finlayson, 2003; Kniskern et al., 2008; Wilcox et al., 2013;
Wright, 2012). The situation is worse for children with rapidly changing
levels of ability or growth (Lau et al., 2008; Li Pi Shan et al., 2012;
Wilcox et al., 2013) or in the case of certain progressive pathologies (Li
Pi Shan et al., 2012) that involve rapid turnover of ATs. In these situa-
tions, the reuse of ATs that are no longer appropriate provides an
affordable alternative to expensive equipment for elderly and people
with disabilities in need of them.
2.2. Environmental benets
Environmental concerns justify the reuse of ATs. Most ATs fall under
the obligations of their medical device (MD) class provided for by Eu-
ropean regulations (Regulation (EU) 2017/745 of the European Parlia-
ment). French legislation remains ambiguous about the medical device
status of ATs. According to the WHO, any product or equipment used for
a medical purpose, that is, equipment for diagnosis, prevention, moni-
toring, and treatment of a health condition - ts the denition of a MD
(World Health Organization, 2019b). MD waste management in the
European Union (EU) is dened in the Waste Framework Directive
(2008/98/EC), as amended by the Directive (EU) 2018/851, which
denes the rules and conditions for waste management operations and
planning taking place in the EU. It is complemented by a few Directives
that set the rules for managing separate waste streams (e.g., packaging,
electronic, etc.). The central principle of the EU waste management, as
dened in Article 4 of the Waste Framework Directive, is referred to as
the “waste hierarchy” (Hansen et al., 2002). The waste hierarchy de-
termines different waste management options based on environmental
and resource efciency principles. Operations generating negative
environmental impacts are considered undesirable and should be pro-
gressively limited, and ultimately replaced by waste management op-
erations that are considered more resource efcient and
environmentally sound (European Commission, 2008).
Fig. 1 describes the waste management hierarchy: (a) waste pre-
vention including reuse; (b) preparation for reuse; (c) material and
biological recycling; (d) energy recovery from waste; and (e) disposal to
I. Barbet et al.
Resources, Conservation & Recycling Advances 15 (2022) 200094
3
controlled or uncontrolled landlls, land, or water.
Waste prevention equals zero waste generation, and reuse prevents a
product from becoming waste in the rst place. However, step (b) might
entail the refurbishing of a waste into a reusable product. The term
“reuse” is dened in the Waste Framework Directive as “any operation
by which products or components that are not waste are used again for
the same purpose for which they were conceived” (European Commis-
sion, 2008; Article 3). Preparing for reuse is dened as “checking,
cleaning or repairing recovery operations, by which products or com-
ponents of products that have become waste are prepared so that they
can be reused without any other pre-processing.” Product repair,
refurbishment, and remanufacturing are all considered to be reuse op-
erations (Ijomah and Danis, 2012). These operations are often preferable
to recycling or manufacturing of new products. They save material, re-
sources and energy. They reduce greenhouse gas emissions, and lead to
safer handling of potential toxic substances (Sundin and Lee, 2012). AT
reuse programs are more concerned with Prevention and Preparation for
reuse.
2.2.1. Prevention
Prevention consists in reducing either quantity or harmfulness of
waste produced, or both, by intervening in both its production and
consumption. Production of ATs should consider their lifespan and
duration of use. Companies are urged to assess the environmental im-
pacts of their products. This assessment can be driven by different
methods of production such as life cycle assessment and eco-design.
Such methods ensure better environmental sustainability of medical
devices (Sousa et al., 2021). Regarding consumption patterns, preven-
tion should focus on the non-use of assigned ATs resulting from the
mismatch between AT and personal needs or from a technical failure.
The Norwegian Assistive Technology system model allows users to
address practical/functional daily problems to avoid non-use and repair
of the AT (MacLachlan et al., 2018). In principle, an AT will be repaired
if its repair costs are lower than its residual value (Walsh et al., 2015).
2.2.2. Preparing for reuse
The economics of any reuse program plays a central role in deter-
mining its implementation and long-term sustainability. An AT reuse
focused center has important operating costs (Milios and Dalhammar,
2020) that are primarily determined by the type of activities the center
engages in. In the United States, the “Pass It On Center – the National
Assistive Technology Reutilization and Coordination Technical
Assistance Center” has conducted studies in different states about major
models of technical assistance provision (Phillips and Persaud, 2014;
Walsh et al., 2015). These studies elaborated a classication of all AT
reuse activities and dened Indicators of Quality for Assistive Technol-
ogy Reuse (IQ-ATR) programs of all types. These indicators established
efcient practices in terms of program completion and sustainability
(Pass It On Center, 2007, 2011). Different modalities of transfer between
donors and beneciaries are proposed by these programs: exchange,
reassignment, rehabilitation, reconditioning, and recycling of AT.
Depending on the type of activities supported by the programs,
increased volume of activities translates into higher personnel, trans-
portation, and storage costs. When programs plan to recover used de-
vices, the reuse cost is highly inuenced by their collectability and
redistribution. An efcient reverse logistics network where products are
returned to the supplier uses different types of closed-loop supply chain
(Walsh et al., 2015).
The cost of AT reuse is also inuenced by the product’s design that
conditions the additional workload and time it takes to prepare the
product for reuse. The product must be sorted, checked, cleaned,
reprocessed, reassembled, quality assured, transported and nally
delivered to a recipient. The right type of design can reduce the work-
load required for these tasks which determines eventually a successful
reuse (Vanegas et al., 2018). Furthermore, acceptability of using a
second-hand AT depends on its perceived residual value. According to
Walsh et al. (2015), perceived residual value depends on: (i) product
properties (i.e. products with an initial lower value, or with a high rate
of technological innovation or with a short physical lifespan are not
suitable for reuse) and (ii) on consumers’ preferences (economic,
ecological motivation, attitude towards reuse products, perception of
performance and durability). Generally, both high price of AT and rapid
change in user’s requirements lead to a signicant residual value of
refurbished AT (Walsh et al., 2015).
According to Walsh et al. (2015) and Pass It On Center (2011), some
external factors can also inuence the likelihood of reuse: these include
the absence of conict with producers of new AT, ethical and ecological
motives, and existing legislation. The inuence of legislation is signi-
cant as systems of AT service delivery are part of the local welfare system
and differ greatly according to countries and regions. The scientic
literature on the reuse of AT comes primarily from countries where AT
reuse legislation and regulation exist. In Europe for instance, very little
research can be found on AT reuse programs. Walsh et al. (2015), argue
that this is the result of the European funding models characterized by
Fig. 1. Waste management hierarchy (source: Defra, 2011).
I. Barbet et al.
Resources, Conservation & Recycling Advances 15 (2022) 200094
4
government full cost coverage. This encourages the purchase of new
rather than second-hand AT products. This state of affairs has driven the
ongoing reection in France.
3. Research methodology
Our methods for the design of an assessment tool follows three main
steps: 1) we dened the main objectives and the framework for the
evaluation process based on the existing literature of reuse of AT; we
designed a program assessment guide built on several existing programs
aiming at improving access to ATs in France; 2) using this assessment
guide to conduct a cross-sectional analysis and evaluation of these
programs to identify the levers and obstacles to running a program. The
main trends are presented in Section 4 as key lessons from the cross-
sectional analysis; 3) Section 5 introduces the design of a matrix of
quantitative indicators as an operational scorecard for stakeholders
(and/or the funders), which is presented as the main result in Section 5.
3.1. Step 1: The evaluation process and the design of the assessment guide
for AT reuse programs (bottom-up approach)
We designed an evaluation grid for AT reuse programs. This grid was
been constructed using three categories of sources: a) the gray literature
related to the management of public policies; b) the cross-analysis of
several monographs of programs involved in promoting access to ATs
funded by the 2015 CNSA call for projects, with potential for second-
hand supply practices; c) a review of the scientic literature on AT
provision programs.
The guide for AT reuse programs is an evaluation reference frame-
work taking the form of a checklist in an Excel table. It covers the eight
dimensions included in the French approach of “public action modern-
ization” as a main intervention area of public policies implemented by
the Minist`
ere de la transformation et de l’action publiques (Ministry of Public
Transformation and Action). Fig. 2 presents the main steps involved in the
value chain of a public action: once specic needs are identied in a
territory, objectives are assigned to new programs, resources are allo-
cated, and actions are undertaken. The evaluation aims at the results of
the public actions, and more generally, the programs are evaluated on
their overall impact. It is necessary to evaluate the value chain through a
Fig. 2. Value chain of a public action in France and evaluative criteria. Adapted by the authors from MTAP (2015).
I. Barbet et al.
Resources, Conservation & Recycling Advances 15 (2022) 200094
5
set of criteria. To implement the evaluation process, eight dimensions of
the program can be characterized: objectives and challenges; relevance
and external coherence; internal coherence; implementation; effective-
ness; efciency; sustainability; and utility. These eight dimensions are
dened and described in Fig. 2.
As a result, the guide for AT reuse programs provides key questions
and in-depth criteria for each dimension that can help stakeholders,
project leaders, or funders to identify strengths and weaknesses of their
current program or of their ongoing project. This guide is based on the
same principle as the American guide “Indicators of quality for assistive
technology reuse – IQ-ATR” (Pass It On Center, 2011; Phillips and Per-
saud, 2014), adapted to the French context and to the evaluation re-
quirements of public policies.
Each dimension can be documented using qualitative data such as
statements, activity reports, job descriptions, contracts, interviews. The
guide is built on empirical knowledge of experiments and surveys. In
France, access to ATs is dominated by the purchasing of new equipment
and alternative circular economic models are still rare. In this context,
we compared this approcach to seven innovative models of AT provision
with different status of stakeholders, target beneciaries, main objec-
tives of the program, and types of ATs provided. Our approach consists
in identifying alternative models rather than in comparing them in terms
of relative performance. We reviewed the available documentation
(website, activity report, etc.) for each program. We conducted half day
on-site visits consisting of an interview with the person in charge of the
program and, as deemed necessary, other key team members (president,
occupational therapist, etc.). Fig. 3 and Appendix A provide an overview
of the seven programs. This gure positions the programs regarding two
criteria, i.e. the target beneciaries in terms of territories of action and
of eligibility conditions, the activities carried out with regard to the
recycling of technical aids.
3.2. Step 2: Proceeding to cross-sectional analysis
The qualitative study and cross-sectional analysis, based on step 1
results, were conducted in two separate stages:
- during the exploratory work, the different interviews of ten programs
that were funded in 2015 by the CNSA allowed an initial charac-
terization of each to be built through a cross-sectional analysis:
particularly, activities undertaken (advice and support, circulariza-
tion of ATs, and accessibility to ATs), levers of activities (reim-
bursement of ATs, for example), gathering and renovation of the ATs,
and the economic conditions for the sustainability of the programs.
This rst stage generated valuable material to enhance the evalua-
tion guide and its eight dimensions, a set of criteria and, if applicable,
the identication of indicators;
- once the evaluation guide was “ready-to-use” as a reference assess-
ment frame, it was applied to a selection of seven programs, some of
which were not in the subset of ten programs. The assessment was
rst conducted dimension by dimension, and then was synthesized
through management project tools to provide a critical analysis of
each program. During this diagnostic process, we aimed to collect
self-elaborated indicators to design the matrix scorecard.
3.3. Step 3: Designing the matrix scorecard or dashboard of quantitative
indicators (top-down approach)
The in-depth study of the programs made it possible to construct a
matrix of quantitative indicators as a tool for steering, analyzing, and
evaluating program activity. This matrix was discussed by the project
leaders, the program funders, and external members of the advisory
committee during a workshop in fall 2019.
The matrix is composed of three perspectives: the direct beneciaries
of the project, the project leaders, and society, including the State, the
funders, and citizens, for instance for their concern, for instance, about
waste management and use of resources. For each perspective, four
categories of evaluation criteria had to be identied: attractiveness and
accessibility; organization of services and functions; quality and socio-
economic value of the service; and cost and price of the services
(Table 1).
Some of the indicators had already been collected by some programs
(such as activity indicators) at the time of investigation, while others
would require specic reporting by program holders, local authorities,
or even at the national level.
Fig. 3. Seven French programs suitable for an AT circular economy in 2019 according to their beneciaries and their waste management activities.
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Resources, Conservation & Recycling Advances 15 (2022) 200094
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4. Seven French AT reuse programs: cross-sectional analysis and
key lessons
To identify the levers and obstacles to promoting AT prevention and
reuse programs, the evaluation grid was applied to the seven programs
selected for the evaluation process and for the identication of relevant
steering indicators (Fig. 3, Appendix A). This investigation was con-
ducted between March and July 2019 and it is possible that some pro-
grams have evolved since then, particularly in terms of their goals and
issues.
4.1. Objectives and challenges
Most of the programs evaluated had several objectives that may have
evolved over time. The objective most frequently pursued by the pro-
grams related to the accessibility of ATs: equal treatment for elderly and
people with disabilities (in France, people with disabilities benet from
certain aids for the acquisition of ATs that are not available to elderly
people), affordable access and shorter access times (currently in France
the access time can be up to several months, because of delays in pro-
cessing les for the nancing of certain AT). Another widely shared
objective was to ensure that Ats were tting individuals to the in-
dividual’s needs and used properly. Four of the seven programs also had
the explicit objective of creating an eco-responsible circuit for ATs.
All programs developed activities related to the provision of ATs,
including maintenance, sanitization, disinfection, distribution, and
installation at home. All but one also offered collection, refurbishment,
and aftersales service or maintenance. On the other hand, activities
related to the proper matching of ATs to individuals’ needs were not
always fully covered. While all programs provided information, advice,
and support in handling the equipment at the time of delivery, they did
not systematically provide recommendations or follow-up on the use
overtime of the equipment at home. This generally implied the
employment of occupational therapists in the program. Moreover, there
was a great diversity of ways to provide ATs (donation, loan for trial or
use, rental, sale), while French regulations encourage AT acquisition and
ownership. Thus, while loan for trial was widely offered, loan for use
was rarer, as was donation. Rental and sale of new ATs were quite
common, while sale of second-hand ATs concerned three of the seven
programs. Only one program covered all these options.
Legal status could also vary between enterprise and association sta-
tus, which has an impact on the AT market: social economy enterprise
status places the program in a situation of local competition with other
AT distributors, while patient association status confers on the programs
a particular form of legitimacy and repute with the target audiences.
Moreover, companies must develop a sustainable economic model,
whereas this is not the case for associations.
4.2. Relevance and external coherence
To ensure their territorial anchoring, the programs have concluded
formal or informal partnerships that could - and most often did- involve
patient and users’ associations, healthcare and medico-social in-
stitutions, independent healthcare professionals and even professional
integration actors when the program participates in the inclusion of
disabled workers in the workplace. The programs that offer second-hand
ATs had also the stakeholders of the recycling sector (waste disposal
centers, recycling centers, etc.) as partners. On the other hand, part-
nerships with other AT distributors in the territory were rare or non-
existent and it should be noted that innovative programs can be direct
competitors (i.e., threats) for them on their territory.
Regardless of the dominant activity (provision of ATs or matching
them with user needs), programs overall made little use of outsourcing
services. When a function is outsourced, it is because it being based on
quite technical skills, whether for renovation, or for expertise/advice
from a professional on which AT to use for specic needs. The use of
outsourcing is not related to the age of the program, but rather to its
ambitions to cover all provisioning functions: the three programs that
made more use of outsourced services were also those that offered all the
activities in the value chain (provisioning and matching of ATs). This
allowed them to complete the service package or to strengthen pro-
cedures. However, the price to pay depended on the partner, which
could weaken the program: it is important to note that the main skills
missing at the time of the program launch were logistics and refur-
bishment expertise. This probably hindered the deployment of programs
around the supply of second-hand ATs. Only one program had these
skills at start-up, as it already focused on recycling and refurbishment
skills and developed ATs as a complementary branch of its activity.
Thus, increasing programs’ skills by hiring new people (internalization)
or nding partners to delegate certain activities (outsourcing) is neces-
sary for their success. All the programs that had not chosen referral
activities as part of their scope of work seemed to be gradually opening
their scope of practice to this activity, by recruiting or purchasing the
services of occupational therapists.
4.3. Internal coherence
There was no relationship between the conditions of concrete
implementation of the project and the status (private enterprise from the
social economy sector or private association) of the program holder:
overall, the schemes belonged to the social and solidarity economy and
pursued a collective interest. Moreover, public subsidies had played a
crucial role in the launch of projects, providing substantial resources for
initial investments.
At the operational level, programs did not rely heavily on formalized
needs assessments. In term of production processes, standardization
practices vary considerably, but programs that were in a dissemination
strategy tended to formalize their procedures. In all cases, the main
difculties in terms of “routine” arose from the fact that labor market
skills were sometimes scarce: this is the case for AT renovation techni-
cians for whom there is no tailored training in France. Training followed
an on-the-job approach on their repair skills and their experience in
Table 1
Matrix scorecard for program monitoring.
I. Barbet et al.
Resources, Conservation & Recycling Advances 15 (2022) 200094
7
renovating other types of products.
4.4. Implementation
To evaluate the level of implementation, several criteria were
examined: concrete launch of the activity, respect of the timetable of
deployment, evolution of the activity area during deployment, setting
up of the conditions for sustainability, and formalisation of operating
procedures. Not surprisingly, the main determinant of program reali-
zation was its duration: those created up to the 2000s were fully effec-
tive, while those created from 2015 onwards were currently growing
and the most recent ones were not yet operational, sometimes due to
activity reorientation. In general, the programs provided high-quality
services to their users. Despite identifying conditions for their sustain-
ability, sustainability was not always achieved to date.
4.5. Efciency
As before, mature programs were more likely to meet all their ob-
jectives. Objectives related to nancial barriers to access, equal treat-
ment, or the creation of an environmentally responsible circuit were
consistently met. The objectives that were only partially achieved were
either related to a lack of access to ATs (probably due to administrative
problems or insufcient stock) or to the approach of the use of ATs by
occupational therapists. In the latter case, the difculty stemmed mainly
from excluding from the original program roadmap the issue of quality
and of matching the AT with users’ needs.
Setting explicit objectives at the outset of the activity and adjusting
them as objectives changed (frequently) over time was essential to
assessing program effectiveness: some programs were no longer effec-
tive according to their initial objectives, but rather according to the new
objectives set as they grew. However, it is difcult to assess the ef-
ciency of programs as they did not collect tangible indicators on this
subject. Apart from one program, indicators were rare, yet they could
help support the development of these programs. This included the need
to develop four types of indicators:
- efciency indicators related to the circular economy of ATs: for
example, the average lifetime of ATs;
- efciency indicators related to time to access ATs;
- efciency indicators related to improvement of nancial access to
ATs: for example, the average price of a renovated AT compared to
the average price of new.
- efciency indicators related to support of individuals: for example,
the AT dropout rate.
4.6. Effectiveness
Mostly, the schemes had been supported by a certain number of
grants, donations, and sponsorships. Funds had been managed in a
pragmatic and economical way, with a concern for optimization. How-
ever, these programs had difculty in nding a self-nancing business
model.
The main limitation lay in the obstacles to designing a business
model based exclusively on the circular economy of ATs: at the time of
the study, the regulatory context did not favor this type of activity since
the principle of reimbursement of new ATs, enforced in France, did not
apply to second-hand ATs. Program leaders had therefore often strug-
gled to nance innovative approaches and ultimately turned to rentals of
new ATs that could be reimbursed by public health insurance (although
in limited number), to provide the resources to develop their second-
hand ATs’ activity.
4.7. Sustainability
Regardless of the activities carried out, several conditions must be
met to allow for the dissemination of the programs. The rst condition is
to nd and implement an effective business model that allows for long-
term self-nancing (particularly) if the projects intend to avoid public
subsidies. The second condition, on the over hand, is to benet from
strong institutional support at start-up of the activity but also during the
program’s lifetime. This support must be both nancial and functional,
and at the level of the territory (referral of the public by medical–social
interaction, communication, sharing of good practices and experience,
outsourcing of some activities, etc.). The third condition is to construct
of a solid network of partners to maintain good relationships with the
classic suppliers of ATs (also suppliers of spare parts that are essential for
renovation). To maintain such relationships, programs targeted a pre-
cise area of activity that only partially overlapped with that of suppliers
(e.g., they did not propose to sell new “consumables” such as inconti-
nence and hygiene products). The fourth condition for sustainability and
expansion concerns the formalisation of activities: formalisation of the
offer, operating procedures, job descriptions, creation of contractual and
monitoring tools for materials provided, and tools for managing requests
and stock. Also, the competence and commitment of the teams are a
major lever for sustainability.
For some programs, the question of dissemination did not arise,
because the program was either inherently territorial or already national
(e.g., in the case of a national association focusing on a rare disease).
Other mature programs that wished to develop their activity at the na-
tional level generally did so without competing against each other, by
deliberately choosing unexplored territories. The pool of second-hand
ATs remained limited and requires promotion of the activities to
collect and renovate AT and to make them available.
For this purpose, a study of the needs and resources of the territory
was systematically conducted by the head ofce of the company. This
also led to the search for harmonization of practices between territories
and thus to the design of a toolbox and formalisation of the processes.
Such organization saved time and accelerated the launch of activities. In
addition, it made it possible to dene target outcomes to be achieved at
each acceleration phase, to make comparisons between local structures,
and to guarantee the type and quality of the offer.
4.8. Utility
At the time of our investigation, there were no outcome indicators
that could be routinely measured by the schemes. This was due to dif-
culties in identifying them: quality of life scores, autonomy scores, fall/
fracture rates, duration of use of technical aids, and so on. Program
leaders generally used satisfaction surveys, which were not homogenous
or validated by public funders. In the short term as well as in the long
term, these impacts are more difcult to measure, however they are key
to the evaluation of programs: the impacts are on users’ quality of life
and on the environment. The use of socioeconomic evaluation could
potentially provide a better understanding of the impact of the program,
assessing monetary benets for health and monetary benets resulting
from better access to ATs and also from better management of scarce
environmental resources.
5. A matrix scorecard for prevention and AT reuse programs
Evaluation in the form of our comprehensive approach has shown
great disparity between the programs, and this is also the case for
criteria and indicators that have been developed. This makes compari-
son and benchmarking difcult to implement. One of the motives of this
research was to design an operational scorecard of relevant indicators,
not only for operational programs, but also for future project leaders or
public funders (Appendix B).
Indeed, more general indicators should be designed to provide public
funders with tools, to help them decide how to allocate resources to
programs. The nal goal would be to estimate the impact of programs on
society, including altruistic concerns (e.g., better access to ATs and a
I. Barbet et al.
Resources, Conservation & Recycling Advances 15 (2022) 200094
8
better quality of life for beneciaries) as well as environmental ones (e.
g., better management of resources and waste), so this would ideally
imply consideration of program costs as well as results. Costs should
include not only direct costs (investment, operations, including saved
costs relating to the second-hand market) but also indirect costs (e.g.,
productivity of beneciaries, if relevant for people with disabilities) and
intangible costs (withdrawal of resources from the environment, waste
management, and loss of quality of life for beneciaries and their
caregivers, etc.). This approach would require methodological consid-
eration of 1) the way benets or losses relating to the quality of life (for
beneciaries and caregivers) would be valued (and in particular the
most appropriate scale in the case of disability and loss of autonomy and
its compensation); 2) the way benets or losses relating to environ-
mental resource management would be valued, as negative or positive
externalities.
Thus, the matrix shows not only the indicators that already exist in
some innovative second-hand AT programs, but also the indicators that
should be collected or even designed in the future. Some of these in-
dicators are complex to design and collect at this stage, although they
should ideally be included in the evaluation process. Furthermore, these
evaluations should also include an assessment of accessibility (coverage
of needs), use and proper use of assistive technologies (in the sense of the
abandonment and real usefulness of assistive technologies), horizontal
equity (in the sense of the correction of socially unfair inequalities in
access between categories of beneciaries) and vertical equity (in the
sense of the correction of unfair inequalities in the individual nancial
effort to access the technical aid). Finally, as mentioned before, these
evaluations should ideally consider positive environmental externalities
when a program includes a circular economy dimension and the pro-
vision of second-hand assistive technologies. This approach to general
indicators would of course require in the future more in-depth meth-
odological research. Yet, a subset of criteria is already established,
allowing stakeholders to use it in order to perform a tangible assessment
of their activities and their results.
6. Discussion
This research aimed at developing an analytical framework to
encourage the development of AT reuse programs in France. To design
the evaluation grid for these programs, three categories of sources were
used: the gray literature related to the management of public policies,
the cross-analysis of several French programs’ monographs, and the
scientic literature on AT provision programs. Precisely, this guide was
based on the same principle as the American guide “Indicators of quality
for assistive technology reuse – IQ-ATR” (Pass It On Center, 2011;
Phillips and Persaud, 2014), adapted to the French context and to the
evaluation requirements of public policies. In the United States, assistive
reuse programs emerged from the 1988 federal “Tech Act”, and its 2004
AT “reauthorization” amendment (Cohen and Perling, 2015; Kniskern
et al., 2008; Wilcox et al., 2013; Wright, 2012). The inuence of this
legislation has been instrumental in structuring the AT reuse programs
regulated by the IQ-ATR. According to the ATs Act Data Brief Report, a
compilation of data from 56 AT programs nationwide, 59,149 con-
sumers received a total of 70,673 reused devices from 55 AT programs
resulting in overall savings of $28 million in scal year 2018 (Domin and
Shepard, 2019). Mobility, seating, and daily living ATs accounted for
87% of all devices provided by reuse programs.
Another example of good practice in assistive technology system is
the Norway model that arguably offers the most advanced model of an
AT circular economy (MacLachlan et al., 2018; Nyland, 2018). A sys-
tematic system of refurbishment of used AT includes thorough cleaning
and replacement of worn parts before reuse. In 2016, 439,174 assistive
devices (including accessories) were distributed to 138,150 users (26.3
users per 1000 inhabitants; Sund, 2017). On average, 29% of existing AT
were refurbished devices. The refurbished devices represented a new
price value of approximately 78 million euros. At the end of 2016, a
cumulative total of 414,824 users received one or several assistive de-
vices, representing 8.0% of the population.
Thus, these examples show that in addition to providing an analyt-
ical framework guide to project leaders, there is a requirement for a
legislative framework to sustain them as suggested by Walsh et al.
(2015). Additionally, it is necessary for the public authorities to activate
several levers to support this type of program:
- in legal terms: the reimbursement of second-hand ATs in France, for
which some progress has been evidenced for wheelchairs in 2020 (e.
g., French social security nancing law for 2020);
- in regulatory terms: the denition of a standardized framework that
guarantees the quality of services. This concerns both the quality of
assistance provided to people in choosing and using new and second-
hand ATs (whether they are sold, rented, loaned, or given away) and
the various services provided to individuals and professionals. The
construction of standardized frameworks aims to guarantee quality
products and services and thus earn the trust of AT users, prescribing
health professionals, and funders, and to contribute to the sustain-
ability of the systems. The implementation and massication of these
devices, even in the form of a platform, can only succeed with the
construction of such frameworks;
- in regulation rules for the supply side: greater regulation of the
competition between AT providers is necessary to provide incentives
to cooperate with providers in the second-hand market, or to offer
second-hand ATs also; greater regulation is also required in reuse
practices and in the various stages of the circular circuit.
This study has certain limitations: rst, insofar as the programs
studied depend on the eld of social and solidarity economy, the ques-
tion of formal evaluation often appears to be secondary for project
leaders. They have a highly empirical knowledge of their programs.
Consequently, there are few operational indicators of activity at this
stage. Second, while some of the indicators proposed in the matrix can
be collected by project leaders, others need to be designed soundly from
a methodological point of view and discussed by the company: how to
dene a subset of relevant and shared indicators provided to public
authorities, whose purposes are mainly to assess and compare their
performance in the short term and mid-term; a how to value the quality
of life gained or lost depending on whether the program is accessed; and
how to value the gains or losses depending on the use of the circular
economy. In other words, how to operationalize these measures and
make them accessible to project leaders and evaluators alike in order to
promote them. Third, environmental indicators need to be designed.
Further research is needed to determine the optimal environmental
lifetime (OEL) for each class of AT. Indeed, Hummen and Desing (2021)
showed that the assumption that a longer product use is per se envi-
ronmentally benecial is not necessarily the case for all products. The
optimal environmental lifetime indicator (OEL) takes into account
non-linear dynamics of technological efciency improvements and ef-
ciency degradation during usage, even including lifetime extension
strategies such as re-manufacturing (Hummen and Desing, 2021). The
establishment of this indicator for each type of AT presents a major
research challenge in identifying which AT needs to be rehabilitated in
order to ensure both environmental and social benet.
I. Barbet et al.
Resources, Conservation & Recycling Advances 15 (2022) 200094
9
7. Conclusion
The main challenge of this research was to provide an analytical
framework to encourage the development of reuse programs for ATs, to
increase their accessibility while guaranteeing their performance, and to
decrease their costs, both nancial, social, and environmental, in view of
growing needs. The approach used was both bottom-up and top-down,
drawing on conceptual frameworks and tools from the scientic litera-
ture and on innovative programs already developed in France. This
approach has made it possible to create an evaluation framework for
projects and programs that combines qualitative and quantitative in-
dicators to enable various stakeholders to identify obstacles and levers
to adjust their decisions.
This research is in line with the political priorities set by the French
public authorities in their 2022–2027 roadmap: environmental concerns
are now ranked as one of the ministries’ primary and cross-cutting ob-
jectives, associated de facto with the requirements of their assessment.
Moreover, it covers a eld that has been little explored to date in France,
insofar as the rules for reimbursing new technical aids (purchase or
rental) do not encourage reection on the waste caused by the misuse or
abandonment of AT. The reluctance to use this second-hand market is
also due to the legal liability issues associated with the refurbishment of
equipment.
Since the objective of a sustainable economy is stated as a guideline
for public action in France, the way to achieve it is to promote regulatory
and nancial strategies - as well as further scientic research - that foster
the development of the circular economy, even in the health and long-
term care sector: rationalizing the amount of resources used in order
to improve the well-being of disabled people in France are two mutually
compatible objectives.
CRediT authorship contribution statement
Isabelle Barbet: Conceptualization, Methodology, Investigation,
Formal analysis, Writing – original draft. Laurence Hartmann:
Conceptualization, Methodology, Investigation, Formal analysis,
Writing – original draft. Diane Deville: Conceptualization, Methodol-
ogy, Validation, Writing – review & editing. Marie-Sophie Ferreira:
Formal analysis, Validation, Writing – review & editing, Project
administration.
Declaration of Competing Interest
None.
Acknowledgements
This research was funded by the public national French agency
“Caisse nationale de solidarit´
e pour l’autonomie” (National solidarity
fund for autonomy). Isabelle Barbet and Laurence Hartmann are lec-
turers at the Conservatoire national des arts et m´
etiers (National Con-
servatory of Arts and Crafts), Paris and they are co-rst authors; they
contributed equally to this work. Diane Deville and Marie-Sophie Fer-
reira were contributors for Alcimed France during the research. The
authors are grateful for the review and comments of Maire Harris and
Jean-François Trani. They also thank the referees for their comments
and suggestions.
Appendix A. Seven French programs suitable for an AT circular
economy
I. Barbet et al.
Resources, Conservation & Recycling Advances 15 (2022) 200094
10
#
Appendix B. Matrix scorecard for AT reuse programs
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