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VOLUME 7, ISSUE 2 

 2024 
 

RESEARCH ARTICLE 

 

Theron B, Visagie S. Exploring the need for lower limb prosthetic guidelines in South Africa's private healthcare sector. Canadian Prosthetics & Orthotics 

Journal. 2024; Volume 7, Issue 2, No. 8. Https://doi.org/10.33137/cpoj.v7i2.44450 

  

 

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https://doi.org/10.33137/cpoj.v7i2.44450
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1 

Theron B, Visagie S. Exploring the need for lower limb prosthetic guidelines in South Africa's private healthcare sector. Canadian Prosthetics & Orthotics Journal. 
2024; Volume 7, Issue 2, No. 8. Https://doi.org/10.33137/cpoj.v7i2.44450 

 

 

RESEARCH ARTICLE 

 

EXPLORING THE NEED FOR LOWER LIMB PROSTHETIC GUIDELINES IN SOUTH AFRICA'S 

PRIVATE HEALTHCARE SECTOR 

Theron B *, Visagie S  

University of Stellenbosch, Division of Disability and Rehabilitation Studies, Faculty of Medicine and Health Sciences, South Africa.  
 
  
 

 

 

 

  

 

 

 

 

 

 

 

 

 

 

 

INTRODUCTION   

Lower limb amputations and prosthetic devices have been 

around for ages. Over time, prosthetic materials and 

manufacturing techniques have developed from hand 

tooled wood and leather to metal, space age materials and 

computer aided design and manufacturing. These 

advances allow the manufacturing of prostheses that can 

restore user functionality to before or even above pre-

amputation levels.1 However, more advanced materials are  

 

 

 

expensive and are often not used in lower- and middle-

income countries, including South Africa.2   

According to a 2022 national census there are around 

430,000 upper and lower limb prosthetic users in South 

Africa.3 The average age of persons living with an 

amputation in Africa and South Africa is lower than in 

developed countries and often younger than 60 years of 

age.4 Thus, the functional requirements of occupations must 

be considered when prosthetic components are selected.5 

Lower limb prosthetic services are mainly funded by one of 

four sources in South Africa, namely public and private 

healthcare funding, as well as road, and work-related 

accident funding.  

Successful fitting of lower limb prostheses is dependent on 

optimal prosthetic component prescription, based on a 

 
OPEN  ACCESS 

ABSTRACT 

BACKGROUND: Evidence based guidelines can assist with prosthetic component selection and clinical 

intervention. There is limited evidence on lower limb prosthetic prescription guidelines in the South African 

private health care sector. 

OBJECTIVE: To explore the need for lower limb prosthetic prescription guidelines in the South African private 

healthcare sector. 

METHODOLOGY: Three main funders of lower limb prosthetics in the South African private healthcare sector 

(Road Accident Fund (RAF), Workmen’s Compensation Fund (WCA), and Council of Medical Schemes 

(CMS)) were explored using a case study design. Data were collected from six regulatory documents, sixteen 

purposively sampled prosthetic users, who received services from these funders, and seven key informants. 

Documents were assessed with the Appraisal of Guidelines for Research & Evaluation II (AGREE II), across 

six domains. Data from users and key informants were collected with telephonic, semi-structured interviews 

guided by interview schedules. Interview schedules were self-developed and tailored for each participant 

group. AGREE II data were analyzed descriptively. Inductive thematic analysis was used for interview data. 

FINDINGS: Across cases, the “Scope and Purpose” domain scored the highest: 50% (WCA), 47% (CMS), and 

22% (RAF). “Editorial Independence” scored 0% for all three cases. Other challenging domains were 

“Applicability” (WCA: 17%, CMS: 6%, RAF: 6%) and “Rigour of Development” (WCA: 8%, CMS: 25%, RAF: 

0%). The following three cross-case themes emerged from the interviews: “Guideline Availability and 

Necessity” showed that guidelines were seldom used and that guidelines could be beneficial;  “Purpose of a 

Lower Limb Prosthetic Guideline” indicated that guidelines can support accessible, equitable, ethical, and 

transparent services; and “Guideline Development Requirements” explained that an evidence based 

collaborative process, facilitated by an independent body should underscore guideline development. 

CONCLUSION: Evidence based, standardized, transparent guidelines will be beneficial to direct prosthetic 

service delivery in the South African private healthcare sector. The guidelines must be applicable, rigorously 

developed, and show editorial independence. 

 

 

ARTICLE INFO 

Received: December 11, 2024 

Accepted: February 4, 2025 

Published: February 12, 2025 
 

CITATION 

Theron B, Visagie S. Exploring 

the need for lower limb 

prosthetic guidelines in South 

Africa's private healthcare 

sector. Canadian Prosthetics & 

Orthotics Journal. 2024; 

Volume 7, Issue 2, No. 8. 

Https://doi.org/10.33137/cpoj.v

7i2.44450 

KEYWORDS 

Prosthetist; User Experience; 

Prosthesis; Funding Policy; 

Rehabilitation; Lower Limb 

Amputation; South Africa; 

Prosthetic Guidelines 

 

* CORRESPONDING AUTHOR: 

Mr. Bennie Theron, CPO, MSc 

Affiliation: University of Stellenbosch, Division of Disability and 
Rehabilitation Studies, South Africa. 

E-Mail: Benjetheron@live.com 

ORCID ID: https://orcid.org/0009-0006-0487-9050 

 

Journal Homepage: https://jps.library.utoronto.ca/index.php/cpoj/index 

Volume 7, Issue 2, Article No. 8. 2024 

 

 

https://doi.org/10.33137/cpoj.v7i2.44450
https://doi.org/10.33137/cpoj.v7i2.44450
https://doi.org/10.33137/cpoj.v7i2.44450
mailto:Benjetheron@live.com
https://orcid.org/0009-0006-0487-9050
https://jps.library.utoronto.ca/index.php/cpoj/index


 

2 

Theron B, Visagie S. Exploring the need for lower limb prosthetic guidelines in South Africa's private healthcare sector. Canadian Prosthetics & Orthotics Journal. 
2024; Volume 7, Issue 2, No. 8. Https://doi.org/10.33137/cpoj.v7i2.44450 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X THE NEED FOR PROSTHETIC GUIDELINES IN SOUTH AFRICA'S PRIVATE HEALTHCARE 

Theron B and Visagie S, 2024 

comprehensive assessment of physical needs, life roles, 

and the environment in which the person is to function.6,7 

The componentry must match the users’ abilities, goals, and 

daily use requirements.6 Lower limb prosthetic componentry 

which accommodates activity level and user need are often 

expensive with funding not readily available in developing 

markets. However, cost saving should not be the primary 

focus when prescribing prosthetic componentry.7,8 A high 

initial financial investment increase Quality Adjusted Life 

Years9 and decrease future financial expenditure due to 

decreased secondary complications and increased product 

lifespan.10 Thus, higher initial fiscal investment should not 

be seen in isolation as this investment has far-reaching 

positive effects on socio-economic and healthcare 

environments.9,10 Clinical practice guidelines can assist with 

prescribing appropriate prosthetic components in 

accordance to user needs.8  

Clinical practice guidelines provide evidence-based 

recommendations intended to optimise patient care while 

considering the benefits and harms of alternative options.11 

Guidelines provide justification for interventions such as 

prosthetic component selection with transparency to all 

parties involved.8 Comprehensive, effectively implemented 

guidelines can enhance quality and consistency of care.12      

A lack of or inferior guidelines can cause gaps in service 

delivery that can disadvantage the end user.13  

Healthcare funders, prosthetists, rehabilitation specialists 

and prosthetic users must be involved in the development 

of lower limb prosthetic provisioning guidelines, as broad 

stakeholder involvement allows for transparent guideline 

formation beneficial to all parties.8,14 The quality of 

guidelines must be ensured through transparency and 

rigour during development. Central to the process is the 

intended human activity based on functions and anatomical 

characteristics.8 Empirical knowledge is essential. Local 

medical device regulations should also be considered. 

Lower limb prosthetic guidelines have been adopted in 

various sectors in different countries.6,8,15 However, 

information on the effect of lower limb prostheses guideline 

implementation is limited.15  

Anecdotal information suggests little national and/or in-

house guidelines to guide prosthetic service delivery in 

South Africa. Usually, componentry is prescribed and 

funded based on the user`s activity level as determined by 

the Amputee Mobility Predictor with/without Prosthesis 

(AMPPRO/AMPnoPRO).16 Furthermore, Certified 

Prosthetists and Orthotists (CPOs) clinical expertise and 

experience guides prosthetic prescription. Clinical 

knowledge plays an important role in appropriate 

prescription but must be supported by evidence.6,8 Not 

including evidence in prescription decisions may lead to 

deviation in prosthetic prescription as well as over-or under 

treatment. These challenges prompted this study with the 

aim to explore and describe the need for a lower limb 

prosthetic prescription guideline in the private healthcare 

sector in South Africa. 

Conceptual framework 

The updated Appraisal of Guidelines for Research and 

Evaluation (AGREE II) provided a framework for the study 

as well as a document appraisal tool (Figure 1).14 The 

AGREE II framework can be used to develop guidelines and 

evaluate the quality of guidelines. Geertzen et al.8 

successfully used the AGREE II to formulate a lower limb 

prescription guideline in the Netherlands.  

 

Figure 1: The six domains and domain items of the AGREE II 

(adapted from Brouwers et al.14). 

 

Scope & Purpose

• Guideline obejectives are defined.

• Health aspects covered are described.

• Target population is described.

Stakeholder 
Involvement

• Development group included individuals from all relevant 
professional groups.

• Target pupolation input was sought.

• Target users are clearly defined.

Rigour of 
Development

• Evidence was searched systematically.

• In and exclusion criteria in selecting evidence were clearly 
described.

• Methods used to fomulate recommendations were described.

• Health benefits, side effects and risks have been considered.

• Explicit link between recommendations and supporting 
evidence.

• External experts reviewed the guidlelines before publication.

• An updating procedure is described.

Clarity of 
Presentation

• Recommendations are specific and unambigouos.

• Different managment options are presented.

• Key recommendations are easily identifiable.

Applicability

• Facilitators and barriers to application is described.

• Provides advice on how recommendations can be 
implemented.

• Resource implications have been considered.

• Monitoring and/or auditing criteria are included.

Editorial 
Independence

• Views of the funding body did not influence content.

• Competing interests of development group members have 
been recorded and adressed. 

https://doi.org/10.33137/cpoj.v7i2.44450


 

3 

Theron B, Visagie S. Exploring the need for lower limb prosthetic guidelines in South Africa's private healthcare sector. Canadian Prosthetics & Orthotics Journal. 
2024; Volume 7, Issue 2, No. 8. Https://doi.org/10.33137/cpoj.v7i2.44450 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X THE NEED FOR PROSTHETIC GUIDELINES IN SOUTH AFRICA'S PRIVATE HEALTHCARE 

Theron B and Visagie S, 2024 

METHODOLOGY 

An exploratory case study methodology was used because 

it provides insight and facilitates understanding of complex 

phenomena within a defined context. It can explore how 

similar issues are dealt with in different contexts and how 

context influences the phenomenon being researched.17 

Qualitative and qualitative data were collected as illustrated 

in Figure 2. 

The three cases that were explored in the study are the 

main funders of lower limb prosthetics in the South African 

private healthcare sector: 

• Road Accident Fund (RAF) 

• Workmen's Compensation Fund (WCA) 

• Council of Medical Schemes (CMS) 

RAF: The RAF (Table 1) is a social insurance service, 

funded through a national fuel levy, and provides 

compulsory cover to all road users in South Africa. Once 

liability has been accepted, the RAF shall “compensate for 

costs of the future accommodation of any person in a 

hospital or nursing home or treatment of or rendering of a 

service or supplying of goods.”18 Goods and services 

include lower limb prosthetic services. Coverage is provided 

for the remainder of the beneficiary’s life. For the first time, 

the RAF published a product list for reimbursement in 

2022.19 

WCA: The WCA (Table 1) administers the Compensation for 

Occupational Injuries and Diseases Act No 130/199320 as 

amended by the Compensation for Occupational Injuries 

and Diseases Act No 61/1997.21 The Act provides 

compensation for disablement or death caused by 

occupational injuries or diseases. Employees who 

sustained a lower limb amputation due to a work-related 

injury, are automatically covered for life once liability has 

been accepted. An annually published gazette provides 

guidance on prosthetic prescription, eligibility criteria, 

renewal periods, application forms and reimbursable 

professional fees and products.16 The 2023 gazette 

included technologically advanced prosthetic componentry 

for prescription.16  

CMS: The CMS (Table 1) is a statutory body whose 

operational objectives are described in the Medical 

Schemes Act (Act 131 of 1998).22 The CMS regulates and 

monitors the functioning of medical schemes in South 

Africa. Lower limb prosthetics are covered under Prescribed 

Minimum Benefits (PMB), the minimal level of care that the 

medical scheme is obliged to fund without copayments or 

deductibles. Prosthetics should be funded in the private 

sector at least equal to what is provisioned for in the public 

sector.23,24 CMS has published a guideline document on 

amputations (non-specific) which outlines the basic 

coverage that medical schemes should offer to their 

members.25 

 

RAF WCA CMS 

Quantitative 

methodology 

Qualitative 

methodology 

Case study methodology: Post positivism paradigm 

Semi structured interviews: Key informants from the private prosthetic sector 
- Expert purposive sampling 

Cases 

Lower limb prosthetic policy appraisal: AGREE II instrument 

Semi structured interviews: Lower limb prosthetic users: 
- Deviant purposive sampling 

- Accessed through prosthetists in private practice 

Conceptual framework: AGREE II tool  

Figure 2: An illustration of case study methodology through a mixed method approach used in the study. 

https://doi.org/10.33137/cpoj.v7i2.44450


 

4 

Theron B, Visagie S. Exploring the need for lower limb prosthetic guidelines in South Africa's private healthcare sector. Canadian Prosthetics & Orthotics Journal. 
2024; Volume 7, Issue 2, No. 8. Https://doi.org/10.33137/cpoj.v7i2.44450 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X THE NEED FOR PROSTHETIC GUIDELINES IN SOUTH AFRICA'S PRIVATE HEALTHCARE 

Theron B and Visagie S, 2024 

The Public healthcare sector was excluded from the study 

as the purchasing methods and service delivery 

mechanisms differ in each of the nine provinces in South 

Africa and differ from methods used in the private sector. 

The three private funders have a homogenic approach to 

funding lower limb prostheses. The Public healthcare sector 

receives funding from the National Healthcare budget of the 

Department of Health (DoH) which provides the general 

public with access to prosthetic care (although basic). The 

DoH has various orthotics and prosthetic facilities in each 

province where CPO’s are employed by DoH to 

manufacture and fit prosthetic devices. These facilities are 

fully financially dependent on DoH for (but not limited to): 

infrastructure, facility maintenance, human resources, 

orthotic and prosthetic components and consumables, as 

well as general running costs of an orthotic and prosthetic 

facility.   

Data sources 

Data were collected from documents, key informants, and 

lower limb prosthetic users.  Documents were retrieved from 

the public domain, as a formal request for lower limb 

prosthetic prescription guidelines, regulatory frameworks, 

and/or policies to the three entities yielded no response.  

Seven key informants were purposefully sampled using 

expert purposive sampling.26 They included management 

level employees from the three cases, as well as individuals 

from educational institutions, professional bodies, and 

prosthetic component suppliers. The key informants have 

knowledge and experience working in the sector and could 

give insight into current practices and the need (or not) for 

a lower limb prosthetic prescription guideline.  The contact 

details of these individuals are available in the public 

domain. They were contacted via phone by the researcher. 

The aim of the study and their role were explained, also that 

the interview would be audio recorded for accurate 

transcriptions. After willingness to participate in the study 

was expressed, a study information leaflet and consent form 

for virtual data collection were sent via email. Once the 

signed informed consent was received, a telephonic 

interview was scheduled.   

Sixteen lower limb prosthetic users, whose prostheses were 

funded by one of the three cases, were sampled through 

maximum variation purposive sampling. The study 

population of lower limb prosthetic users was unknown and 

could not be accessed through a database. CPO’s working 

in the private healthcare sector in various geographical 

regions of South Africa were contacted and requested to 

reach out to possible lower limb prosthetic users to 

participate in the study. Twenty-one possible participants 

were identified by CPOs based on the inclusion and 

exclusion criteria.  CPOs asked verbal consent to share 

their contact information with the researcher.  

Prosthetic user inclusion criteria: 

• Persons with major lower limb amputation/s (unilateral 

or bilateral). 

• Persons who received a lower limb prosthesis at least 

six months before commencing data collection.   

• Insured with the RAF, WCA or a private medical scheme 

registered with the CMS. 

• Ability to communicate in any of the official languages in 

South Africa. 

Prosthetic user exclusion criteria: 

• Lower limb prosthetic users who had stroke, spinal cord 

injury, or traumatic brain injury.  

• Persons who could not participate in a virtual or 

telephonic interview due to lack of access to necessary 

hardware or speech impairments.  

• Persons who could not provide informed consent due to 

cognitive impairments. 

The researcher contacted all twenty-one possible 

participants by telephone; five did not respond. The study 

was explained to them, and the provisional consent for their 

participation in the study was obtained. The study’s 

information leaflet and consent form for prosthetic users 

were sent to participants via email.  

Sixteen individuals completed the consent form and sent it 

back to the researcher, whereafter an appointment for an 

audio recorded interview was made. Lower limb prosthetic 

Table 1: Overview of lower limb prosthetic funders in South Africa.  

 RAF WCA CMS Public Health Sector 

Reimbursement system 

Medical schemes 
professional fee tariff list + 
NAPPI codes (medicine, 
consumables and devices) 

Annual published 
Government Gazette 

Medical schemes 
professional fee tariff list + 
NAPPI codes (medicine, 
consumables and devices) 

Subsidised by government 
with patient co-payment 
based on income* 

Responsible department Department of Transport 
Department of Employment 
and Labour 

Department of Health Department of Health 

Percentage of population 
eligible for coverage 

100% 
67% (aged between 15-
64)** 

15%*** 100% 

Funding method Fuel levy 
Compulsory deduction from 
salary or wage 

Medical Schemes via 
members private monthly 
contributions 

National Health Budget 

 

* https://www.westerncape.gov.za/general-publication/western-cape-government-hospital-tariffs-overview?toc_page=3 

** https://census.statssa.gov.za/#/ 

*** https://www.medicalschemes.co.za/preliminary-industry-trends/ 

 

https://doi.org/10.33137/cpoj.v7i2.44450
https://www.westerncape.gov.za/general-publication/western-cape-government-hospital-tariffs-overview?toc_page=3
https://census.statssa.gov.za/#/
https://www.medicalschemes.co.za/preliminary-industry-trends/


 

5 

Theron B, Visagie S. Exploring the need for lower limb prosthetic guidelines in South Africa's private healthcare sector. Canadian Prosthetics & Orthotics Journal. 
2024; Volume 7, Issue 2, No. 8. Https://doi.org/10.33137/cpoj.v7i2.44450 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X THE NEED FOR PROSTHETIC GUIDELINES IN SOUTH AFRICA'S PRIVATE HEALTHCARE 

Theron B and Visagie S, 2024 

users who were both satisfied and dissatisfied with their 

prosthesis were included in this study.26 To further ensure 

variation, prosthetic users were sampled to include all 

sexes, age groups, major lower limb amputation levels and 

urban and rural lower limb prosthetic users. Data saturation 

was reached after sixteen interviews. Although lower limb 

prosthetic users of only six out of the nine provinces in 

South Africa were interviewed, the cohort included both 

urban and rural lower limb prosthetic users. The three cases 

studied operate the same across all provinces thus the 

experiences of lower limb prosthetic users would be similar.  

As the study was novel, there was no available questions 

which could have been accessed or informed the interview 

schedule. The interview questions were formulated based 

on the AGREE II tools six domains and researchers 

experience in the industry. All interview schedules were in 

English, and interviews were conducted in both English and 

Afrikaans (although any official South African language 

could have been accommodated if the need had arisen). 

Data collection  

The AGREE II reporting checklist was used to appraise 

documents. The AGREE II consists of 23 items in 6 

domains, scored on a scale from 1 (strongly disagree) to 7 

(strongly agree). Domain scores are calculated by summing 

item scores and scaling the total as a percentage of the 

maximum score.27 Higher AGREE II scores indicate higher 

quality guidelines. A guideline can be “strongly 

recommended” if four (or more) out of the six domain scores 

are above 60%.28 Guidelines can be “recommended with 

provisions or alterations” if at least two out of the six 

domains scored between 30%-60%. Items of the AGREE II 

are valid and useful. The tool is “appropriate, easy to use, 

and helpful in differentiating guidelines of varying quality”.29 

The two authors appraised the documents individually after 

which domain averages were calculated. 

Qualitative data were collected through semi-structured, 

telephonic interviews, by the first author between October 

2022 and April 2023. Two interview schedules, informed by 

the AGREE II, were developed for the key informants and 

users respectively.  

Prosthetic user questions: 

• Can you please describe the process of getting your 

current prosthesis?   

• What information was available to help you understand 

the process?  

• To what extent was your opinion on the type of 

prosthesis and components considered?  

• What could your funder have done differently in this 

process?  

• What advice do you have for other new lower limb 

amputees in accessing prosthetic care? 

 

Key informant questions: 

• What challenges do we experience in lower limb 

prosthetic prescription and provision in the South African 

private healthcare sector?  

• What role can lower limb prosthetic guidelines play in 

prosthetic prescription in the South African private 

healthcare sector?  

• What would the ideal situation be in the prescription of 

lower limb prosthetics in the private healthcare market? 

Data analysis 

Data were analyzed for each case individually after they 

were integrated. Data from the AGREE II reporting checklist 

were collated and summarised. Inductive thematic analysis 

was used to analyze qualitative data. After coding, 

provisional themes were developed separately by the 

authors. Consensus was reached and themes were named 

and defined. 

Rigour 

Case study methodology allows different facets and views 

of a phenomenon to be explored, through multiple cases 

and in-depth analysis of multiple information sources to 

increase the credibility of the study.17 Credibility was further 

enhanced through purposive sampling and data 

saturation.30 Transferability was supported by describing 

the cases and providing demographic information on 

participants.17 Confirmability was supported through 

triangulation and researcher reflexivity.30 Dependability was 

sought through triangulation, researcher reflexivity and the 

presentation of limitations.30 

Ethical considerations 

Ethical approval was obtained from the health research 

ethics committee at Stellenbosch University (N22/01/002). 

Participation in the study was voluntary. The informed 

consent form was sent to participants electronically for them 

to sign and return before the interview was scheduled.31 

RESULTS 

Document analysis 

The following documents were assessed: 

• Road Accident Fund Act (Act 56 of 1996),18 and Road 

accident fund medical tariff (19 August 2022, No 

46747).19  

• The Compensation for Occupational Injuries and 

Disease (COID) Act (Act 130 of 1993)20 and the annually 

published Government Gazette (Volume 693, March 

2023. No 48299).16   

• The Medical Schemes Act, (Act 131 of 1998)22 and the 

CMScript - Amputations (issue 2 of 2023).25   

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6 

Theron B, Visagie S. Exploring the need for lower limb prosthetic guidelines in South Africa's private healthcare sector. Canadian Prosthetics & Orthotics Journal. 
2024; Volume 7, Issue 2, No. 8. Https://doi.org/10.33137/cpoj.v7i2.44450 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X THE NEED FOR PROSTHETIC GUIDELINES IN SOUTH AFRICA'S PRIVATE HEALTHCARE 

Theron B and Visagie S, 2024 

The highest score overall was 50% (WCA, Scope and 

Purpose). All three cases scored 0% for Editorial 

Independence. Two WCA domains, Scope and Purpose 

and the Clarity of Presentation, scored 50% and 44% 

respectively. Two CMS domains, Scope and Purpose and 

Stakeholder Involvement, scored 47% and 30%, 

respectively. RAF scores were below 30% in all domains 

(Table 2). 

Demographic information of participants 

Prosthetic users ages ranged from 4 to 66 years. In the 

instance of minors, their mothers were interviewed. The 

average time since amputation was 12 years (Table 3). Key 

informants were employed between two and fifteen years in 

their current role, which provided the basis for sampling 

(Table 4). 

Table 2: AGREE II domain scores. 

Domains RAF score WCA score CMS score 

1-Scope and Purpose 22% 50% 47% 

2-Stakeholder Involvement 11% 22% 30% 

3-Rigour of Development 0% 8% 25% 

4-Clarity of Presentation 19% 44% 25% 

5-Applicability 6% 17% 6% 

6-Editorial Independence 0% 0% 0% 

Recommend for Use No With modifications With modifications 

 

Table 3: Demographic details of user participants.  

Patient ID Sex Age* Occupation 
Amputation 

level 
Years since 
amputation 

Year of 
amputation 

Reason for 
amputation 

Province 

RAFU1 Male 29 Mechanic Transtibial 5 2018 
Motorbike 
accident 

Gauteng 

RAFU2 Male 28 
Lecturer - 

Engineering 
Trans-femoral 12 2011 

Motorbike 
accident 

North West 

RAFU3 Female 35 Unemployed Trans-femoral 4 2019 
Pedestrian 
accident 

Western Cape 

RAFU4 Male 16 Scholar Trans-femoral 8 2015 
Pedestrian 
accident 

Western Cape 

RAFU5 Female 63 Administrator Transtibial 18 2005 
Pedestrian 
accident 

Gauteng 

RAFU6 Male 47 Electrician 
Knee 

disarticulation 
5 2018 

Motorbike 
accident 

Gauteng 

WCAU1 Male 53 Unemployed Transfemoral 8 2015 
Work related car 

accident 
Eastern Cape 

WCAU2 Male 52 
Supervisor - 

security 
Transfemoral 16 2007 Gunshot Western Cape 

WCAU3 Male 59 Unemployed Transtibial 3 2020 Falling at work Western Cape 

WCAU4 Male 25 Unemployed 
Knee 

disarticulation & 
Transtibial 

5 2018 
Aerospace 

related incident 
Gauteng 

WCAU5 Male 66 Pensioner Transtibial 41 1982 
Work related car 

accident 
Kwa-zulu 

Natal 

CMSU1 Male 6 Scholar 
Bilateral 

Transtibial 
6 2017 Congenital Gauteng 

CMSU2 Female 5 Scholar Transtibial 5 2018 
Congenital / 

Infection 
Gauteng 

CMSU3 Male 39 Personal trainer Transfemoral 1 2022 Infection Mpumalanga 

CMSU4 Male 60 Project manager Transtibial 4 2019 Diabetic Mpumalanga 

CMSU5 Male 50 
Managing 
Director 

Bilateral 
Transtibial 

50 1973 Congenital Western Cape 

  * Years.  

Table 4: Demographic details of key informants.  

ID Sex Age Type of organization Role at organisation 
Professional 
qualification 

Time at 
organization*  

Province 

KI1 Female 42 Social insurer Acting general medical manager Medical doctor 4 Gauteng 

KI2 Male 50 Regulatory body Former senior clinical manager Medical doctor 6 Gauteng 

KI3 Male 48 Professional body 
Chairman – Professional body & 

practicing CPO 
Orthotist & Prosthetist 3 Gauteng 

KI4 Female 42 Social insurer 
Chief Director – Rehabilitation & 

orthotics 
Occupational therapist & 

MBA 
4 Gauteng 

KI5 Male 34 
Prosthetic device 

supplier 
Head of government sales & 

stakeholder management 
Business management 6 Gauteng 

KI6 Female 50 Academia Senior lecturer Orthotist & Prosthetist 15 Gauteng 

KI7 Female 40 
Prosthetic device 

supplier 
Medical device supplier - owner Psychology 2 Gauteng 

 * Years 

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Theron B, Visagie S. Exploring the need for lower limb prosthetic guidelines in South Africa's private healthcare sector. Canadian Prosthetics & Orthotics Journal. 
2024; Volume 7, Issue 2, No. 8. Https://doi.org/10.33137/cpoj.v7i2.44450 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X THE NEED FOR PROSTHETIC GUIDELINES IN SOUTH AFRICA'S PRIVATE HEALTHCARE 

Theron B and Visagie S, 2024 

Emerging themes   

Three themes with subthemes were identified as shown in 

Table 5. 

Table 5: Themes and subthemes identified from participant data. 

Theme Subthemes 

Guideline Availability and 
Necessity 

 

Purpose of a Lower Limb 
Prosthetic Guideline 

A. Guiding clinical prescription 
responsive to user needs. 

B. Supporting adequate funding in a 
timely manner. 

C. Equity, transparency, and fair re-
imbursement. 

D. Multi-disciplinary rehabilitation. 
E. Case managers. 
F. Information sharing. 
G. A list of preferred practitioners. 

Guideline Development 
Requirements 

H. Driven by an independent entity. 
I. Collaboration and communication. 
J. Use of available evidence. 

 

Theme 1: Guideline Availability and Necessity 

Key informant (KI2) indicated that a lower limb prosthetic 

guideline will “streamline the care and unify the care such 

that the minimum standard is applicable across all sectors”. 

KI3 felt that guidelines, “make it a lot easier and have a lot 

less red tape whereby you can still provide your patients 

with a reasonable prosthesis”. Key informants also 

indicated the current insufficiency of guidelines. KI3 

explained that there “isn’t norms, and the norms that are 

there are old and antiqued”. Although some funders might 

have guidelines, “they don’t like to share their guidelines, 

and keep it as their intellectual property” (KI4). The lack of 

guidelines was confirmed by users of all three cases. 

Lengthy procedures and complex requirements were 

evident.  

“If they can tell you from point A, I want ABCDEF, you can 

send everything one time…it is very difficult…it is very 

complicated” (CMSU2). 

“Beyond reason, takes months. It can even take up to a 

year…everything is a process…[which] makes you 

vulnerable” (WCAU2). 

“It’s a story. Actually, it is a fight” (RAFU2). 

Theme 2: Purpose of a Lower Limb Prosthetic Guideline 

A. Guiding clinical prescription responsive to user needs: A 

prosthesis must support individual function within a specific 

context and life role requirements. Users need their 

prosthesis to enable them to participate in activities 

meaningful to them. Therefore, prosthetic guidelines must 

ensure “patients get the appropriate device, most clinically 

accurate for their diagnosis” (KI4) and “activity level” (KI7). 

Prosthetic component prescription should “not be a blanket 

approach” (KI3) and not be driven by cost containment.  

“Reintegration vocationally, into the community, into family, 

is the one measure which any cost containment initiative 

should be able to measure” (KI1).  

Keeping in mind that “employment and vocational needs 

that are unique” (KI1), persons with lower limb amputations 

“might not be able to return to work and live the fullest life 

because they are being kept back by what they are getting 

from their medical aid, government institution or workmans 

compensation” (KI7). 

Users concurred that they did not always get the most 

appropriate components to support their functioning.  

“I want a knee that can squat, that can run. I am still young, 

I want to run…I want to feel safe, because I used to fall at 

the mall… I just stood up and pretend like I`m okay, but 

when I get home, I feel like ohhh man” (WCAU4).  

Since the same person has different mobility needs due to 

different lifestyle requirements, a second prosthesis with 

components that support specific activities such as sport 

should be considered. Funders frequently do not make 

provision for a secondary prosthesis. Thus, persons with 

lower limb amputations “use the prosthesis [for activities it 

was not meant] and suffer the consequences later” (KI3) or 

the CPO “try create that one shoe fits all hybridized 

prosthesis which might not be perfect for their daily 

ambulation, but at least allow them to attain some form of 

higher activity with regards to sporting events” (KI3). A 

secondary prosthesis is also important when the primary 

prosthesis needs repairs. As explained by RAFU5, “if I take 

the one in for repair, I use the other one”.  

B. Supporting adequate funding in a timely manner: Long 

waiting times were bemoaned by users and Key informants 

alike.  

“Patients’ cases go on for years before they can get help” 

(KI5). “Quite a lengthy procedure” (WCAU5). “The process 

takes flippen [slang for very] long” (RAFU2).  

KI3 explained that “there is one big challenge at the 

moment, and that would be funding.” Although private 

funders fund high end prosthetic components, “you might 

wait a while to be funded for it” (KI7). The biggest concern 

was “giving the correct prescription to the patient” and “at 

least ensuring to get reimbursed for the correct prescription 

made” (KI3). This opinion was confirmed by KI7, “funding is 

the main stumbling block between a patient being able to 

walk or being wheelchair bound or on crutches”. 

“Practitioners are often limited to give the patient the best 

possible solution due to limited funding which limits what the 

patient can achieve” KI7. The RAF “…will try to play out as 

long as they can before they pay” (KI5).  

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Theron B, Visagie S. Exploring the need for lower limb prosthetic guidelines in South Africa's private healthcare sector. Canadian Prosthetics & Orthotics Journal. 
2024; Volume 7, Issue 2, No. 8. Https://doi.org/10.33137/cpoj.v7i2.44450 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X THE NEED FOR PROSTHETIC GUIDELINES IN SOUTH AFRICA'S PRIVATE HEALTHCARE 

Theron B and Visagie S, 2024 

Users agreed. “The medical aid disappointed me…because 

they did not pay for the leg…If they could only fund the 

thing…They must at least fund a mechanical knee in full” 

(CMSU3). In this instance the medical insurance paid 11% 

of the total cost of the prosthesis. The use of the prescribed 

minimum benefit when funding is supplied by medical 

insurance schemes was inconsistent and confusing. “There 

is no standard approach” (KI5) and “It (PMB) is about 

interpretation and manipulation of interpretation…they try 

and make it as difficult as possible” (KI3).  

C. Equity, transparency, and fair re-imbursement: 

Guidelines can assist in ensuring fair, non-discriminatory 

treatment of all people with lower limb amputations. As 

indicated by KI1, “Unified guidelines that speak to 

standardized care where all stakeholders can be held 

accountable should the guidelines not be adhered 

to…ethical conduct on the part of all concerned where the 

shift moves away from what prosthesis provides the most 

financial gain to what prosthesis provide the most in the 

patients activities of daily living” (KI1).  

Having standard guidelines for the provisioning of lower 

limb prostheses could be a win for all stakeholders involved.  

“Rules and regulations with the costing done correctly which 

will be saving money, patients getting better outcomes and 

suppliers getting better sales and reduce waste and abuse 

across the industry” (KI3). “Preventing fraud, over billing 

and unbundling” (KI4).  

Overprescription, related to prescribing more expensive 

rather than appropriate components, is a reality in the South 

African prosthetic industry “Where prescription is written 

more for financial gain than to address the specific needs of 

the patient” (KI5). RAFU6 concurred and explained an 

additional challenge related to overprescription. “There are 

prosthetists who only prescribe the most expensive knees 

although the patient does not have the capability of using it. 

This makes it difficult for other persons with lower limb 

amputations to access such more expensive prosthetic 

knees when they actually need it”.  

The reimbursement of products historically “were not 

(correctly) set up from the start where there was just no 

transparency. Any product could be listed at any price. It 

was a free for all and that is where the mistrust in the 

industry from the funders side” (KI7) emanated from. It 

seemed as if unethical behaviour that involved financial gain 

were practiced by various stakeholders, not only 

prosthetists.  

“With RAF, it’s the lawyers. Everyone is out there for money, 

and they forget about the patient, which becomes a struggle 

for the patient to get a prosthesis” (KI5).  

“You can get a prosthesis, but you have to pay over funds 

into an account whereafter you will receive authorization. If 

you don’t pay funds or don’t put anything on the table, you 

get pushed to the side…the RAF has fired a lot of case 

managers, I think due to corruption” (RAFU6). 

“There is an incredible amount of corruption unfortunately. 

Bribery is a big problem. Unfortunately, prosthetics are 

expensive commodities. At the end of the day, the guys do 

unethical, corrupt things to get the business and to the 

detriment of the patient.” Patients get bribes “in the form of 

cash incentive, fridges, cellphones that sort of things…. This 

undermines the profession, undermines the integrity of what 

we stand for and undermines the patient’s rehabilitation 

outcome at the end of the day” (KI3). 

D. Multidisciplinary rehabilitation: The importance of 

receiving rehabilitation from a multi-disciplinary 

rehabilitation team was stressed.  

“Treating a patient holistically and understanding that the 

patients are full-on individuals that has different aspects to 

them” (KI1) needs to be addressed by “guidelines across 

the board which will unlock funding, treatment and 

rehabilitation” (KI3). 

“There should be a dedicated program set out for any 

person with a lower limb amputation that covers enough 

sessions until that person is strengthened and 

reconditioned to probably where he was when he was still 

healthy and functional” (CMSU5). 

E. Case managers: Throughout the interviews it became 

evident that case managers can play an important role in 

accessing prosthetic care. The performance of the case 

manager mirrored the users’ experience of accessing care. 

RAFU5 had the same “case manager for longer than 10 

years, it goes quick, I don’t struggle”. RAFU2 shared a 

different scenario. “It took me a year to get a new case 

manager [after relocating to another province]. Their 

services were really bad”. This caused delayed access to 

prosthetic care and RAFU2 personally funded the cost of 

prosthetic consumables for “more than two years”. Key 

informants also felt that RAF case managers might in some 

instances not fulfil their roles as required. “Case managers 

are often really frustrating, some of them are really not good. 

Files get lost and patients are not contacted” (KI3).  KI7 

stated, “They don’t answer phones. There is just no 

leadership and pride in what they are doing”. 

F. Information sharing: KI1 recommended “Full-scale 

awareness to claimants to know what they qualify for 

according to the guidelines and to know what benefits are 

due to them…increase level of awareness, information and 

the entitlement to quality medical care” (KI1). 

WCAU5 indicated guideline should include information on: 

• “Best way” to go about accessing prosthetic care. 

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Theron B, Visagie S. Exploring the need for lower limb prosthetic guidelines in South Africa's private healthcare sector. Canadian Prosthetics & Orthotics Journal. 
2024; Volume 7, Issue 2, No. 8. Https://doi.org/10.33137/cpoj.v7i2.44450 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X THE NEED FOR PROSTHETIC GUIDELINES IN SOUTH AFRICA'S PRIVATE HEALTHCARE 

Theron B and Visagie S, 2024 

• “Time periods” for when new components, sockets and 

consumables like liners, prosthetic socks, prosthetic foot 

covers etc. can be accessed. 

• “What is out there” in terms of components for possible 

prescription. 

G. A list of preferred practitioners: A guideline can also 

provide a list of preferred practitioners who provide high 

quality prosthetic care. Most people with a lower limb 

amputation have no reference point on how to identify a 

good CPO. “You start to find your way through to 

somebody…and you find oh no, he is not good anymore. 

So, you go for a second opinion and somebody even better 

or probably even worse” (WCAU5). CPOs play an intricate 

role in the provisioning of prostheses and the experience of 

persons using a lower limb prosthesis. “This is somebody 

you need to be able to go on a journey with because that 

journey is probably going to be for the rest of your life” 

(CMSU5). “Get yourself a good prosthetist…it is a big deal” 

(RAFU2).  

Theme 3: Guideline Development Requirements 

H. Driven by an independent entity: Guidelines should “try 

to find common ground and alignment of different interests” 

(KI2). Thus, an independent body should be established to 

provide a “neutral platform to engage” (KI1). The entity 

should “have no favoritism towards provider or funder and 

develop a guideline that shows fairness towards all parties, 

but most importantly showing value towards the patient” 

(KI4).  

I. Collaboration and communication: KI3 argued that 

successful guideline development should be an “industry 

collaboration” (KI3) following “a multi-faceted approach” 

(KI3) with “a whole team” (KI3). A “multidisciplinary” (KI6) 

and “multi-stakeholder approach is important” (KI1). This 

group of “role players need to come in one room and 

develop something that will work best for the patients and 

for everyone else in the value chain” (KI5) with the “more 

stakeholders the better” (KI6) where all “agree on common 

good” (KI2). Stakeholders include funders, service 

providers and users. “The funder cannot do it without the 

service provider, and the service provider cannot do it 

without the funder” (KI1). Academia was also seen as a 

“major stakeholder” (KI2) as they can do research on “cost 

effectiveness, sourcing of materials to manufacture 

prosthetics and provide training” (K12). 

J. Use of available evidence: Key informants agreed that it 

was not necessary to “reinvent the wheel” (KI3) as “cross 

referencing what we want to do and what is done 

internationally” (KI3) can be done as “international literature 

and experiences, drives a lot of evidence” (KI1). Local 

guideline formation can “borrow knowledge and expertise” 

(KI1) from international counter parts where there “is a 

strong drive on evidence-based medicine” (KI1). The Unites 

States of America and Australia were identified to “have 

similar situations to the South African private healthcare 

environment” (KI4) and have “guidelines which can be 

adjusted to fit the South African context” (KI6). “The 

International Society of Prosthetics and Orthotics which 

have good recommendations” (KI6) can also be 

approached for guidance. 

DISCUSSION 

Although the three cases were guided by different acts, they 

have the same mandate to fulfil – provisioning of lower limb 

prostheses. Thus, it is not surprising that findings were 

similar and overlapping. Findings support the development 

of an evidence-based guideline for provisioning of lower 

limb prosthetics in the South African private sector that can 

guide equitable, fair service delivery and provide clarity on 

treatment pathways, available components and prescription 

criteria as summarised in Table 6.  

Based on AGREE II findings current RAF guidelines cannot 

be recommended for use in the provision of lower limb 

prostheses while WCA and CMS guidelines can be 

recommended for use with modifications.28 However, acts 

and government gazette publications have a more 

Table 6: Summary of study findings.  

Finding: 
There is a need for developing a uniformed evidence-based guideline for the provisioning of lower limb prostheses in the South Africa 
private healthcare sector utilizing the AGREE II tool (main framework) and Delphi technique (for consensus purposes).  

Addressing: Providing clarity on: 

▪ Equitable service delivery. 

▪ Enhance and promoting ethical practice and industry 
transparency. 

▪ Fair reimbursement. 

▪ Prohibiting over-prescription and bribery. 

▪ Encouraging economic activity of lower limb prosthetic users. 

▪ Incorporating multiple stakeholder involvement and processes 
to increase guideline development rigour. 
 

▪ Treatment pathway for lower limb prosthetic users to follow. 

▪ Available prosthetic components for prescription. 

▪ Criteria for a new prosthesis and socket refits. 

▪ Prescription on secondary prosthesis, repairs and 
maintenance of devices, sport and recreational prostheses. 

▪ Rehabilitation treatment pathways. 

 

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Theron B, Visagie S. Exploring the need for lower limb prosthetic guidelines in South Africa's private healthcare sector. Canadian Prosthetics & Orthotics Journal. 
2024; Volume 7, Issue 2, No. 8. Https://doi.org/10.33137/cpoj.v7i2.44450 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X THE NEED FOR PROSTHETIC GUIDELINES IN SOUTH AFRICA'S PRIVATE HEALTHCARE 

Theron B and Visagie S, 2024 

overarching purpose than providing service delivery 

guidelines. Therefore, the low scores of the documents that 

were appraised with the AGREE II were hardly surprising. 

However, the low scores made it clear that these documents 

could not fulfil the role of a prosthetic service delivery 

guideline. The interviews confirmed this, and the data 

identified inconsistencies in products provided, uncertainty 

of processes, long waiting times and insufficient funding of 

products that point to a need for service delivery guidelines. 

Previous work suggested that guidelines can address these 

challenges.8,12,32  

In South Africa resources are constrained and idealistic 

prescription to provide all lower limb prosthetic users with 

everything is not feasible. Thus, a guideline should weigh 

costs against function. However, as far as possible every 

user should be supplied with components which can best 

support their physical, vocational, recreational, and 

environmental requirements.5,12 The guideline should also 

provide guidance regarding the funding of a second 

prosthesis. In healthcare systems that fund secondary 

prostheses, provision of secondary prostheses are more 

prevalent among younger, transtibial prosthetic users with 

high mobility levels, who had non-dysvascular 

amputations.33 The provisioning of sport and recreational 

prostheses are cyclic in nature as a lack of an activity-

specific prosthesis leads to lack of participation and lack of 

participation leads to inadequate justification for an activity-

specific prosthesis.32 

Rejecting applications without providing sound reasons or 

applications taking an inordinately long time to fund are 

determinantal to users’ psychosocial experiences,7,9,34 

quality of Life34 and economic activity.5,35 For children 

specifically, developmental milestones must be met to 

ensure optimal ongoing physical and emotional 

development.36 Not replacing prosthetic limbs timeously to 

accommodate growth and development needs can cause 

irreparable harm.36 

Users described being unsure of processes and dependent 

on CPOs to secure funding. The level of support needed 

from CPOs might have been necessitated through unclear 

procedures, bureaucratic processes, stalling techniques, 

and red tape. A guideline written in plain language can help 

to facilitate user knowledge8 and thus user centered care.37 

Unfortunately, dependence on CPO’s increases the 

administration burden of CPO practices, the size of the 

administrative staff complements, and the cost of supplying 

a prosthesis.  

Case managers can reduce the administrative burden on 

CPOs. They can guide the processes, provide a point of 

contact, provide feedback, assess user needs and much 

more. However, the funder as employer should ensure that 

case managers provide high-quality services and follow the 

correct procedures. Over and above guidelines, this can be 

guided by Standard Operating Procedures and disciplinary 

action.  

A guideline should be in line with the study findings and 

AGREE II domains.27 The domains must be clearly 

identifiable throughout the guideline to ensure that the 

objectives, the issue dealt with (i.e. prosthetic service 

provision) and the target population are clearly described. 

All relevant stakeholders (including the target population) 

must be involved in the development of such a guideline. 

Evidence used to develop the guideline must be rigorous 

and used appropriately. The recommendations must be 

presented clearly and without ambiguity. Different pathways 

and possible deviation in some cases must be presented. 

The guideline must present strategies that can help its 

implementation as well as facilitators and barriers to 

implementation, including resource allocation and 

monitoring strategies. Competing interests of stakeholders 

and the view of the funder must not influence the guidelines. 

As indicated by participants and in the background, 

guidelines have been developed in other settings (mostly 

high-income countries).8,12,32 Information from these can be 

used to assist the development of guidelines in the South 

African private sector. However, caution must be used as 

the contexts differ and Sadeghi-Demneh et al15 found that 

none of the guidelines currently in use internationally have 

been researched to determine their impact on service 

delivery.  

Limitations  

The low numbers of CPOs and rehabilitation team members 

as participants could have limited a broader understanding 

of the available guidelines available for rehabilitating and 

providing prostheses for individuals with lower limb 

amputation. As the study was novel, no existing validated 

interview schedules were available and had to be self-

formulated by the authors. 

CONCLUSION 

The study highlighted the need for evidence-based 

guidelines to guide prosthetic service delivery in the South 

African private sector. Guidelines rather than protocols are 

recommended because guidelines are flexible and allow 

clinical judgement and adaptation to individual user needs. 

Guideline development must be driven by an independent 

body trusted by all stakeholders and follow a patient centric, 

transparent, equitable approach involving multiple 

stakeholders. The AGREE II tool and Delphi technique 

(where consensus has not been reached) can be used to 

facilitate the development process.  

Further research should be conducted to guide the 

formation of a standardised lower limb prosthetic guideline 

facilitated by an independent body (consisting of multi-

stakeholders in the industry) which provides the opportunity 

for adoption by all three cases studied. A method of 

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Theron B, Visagie S. Exploring the need for lower limb prosthetic guidelines in South Africa's private healthcare sector. Canadian Prosthetics & Orthotics Journal. 
2024; Volume 7, Issue 2, No. 8. Https://doi.org/10.33137/cpoj.v7i2.44450 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X THE NEED FOR PROSTHETIC GUIDELINES IN SOUTH AFRICA'S PRIVATE HEALTHCARE 

Theron B and Visagie S, 2024 

reimbursement calculation for professional fees and 

prosthetic components should also be further explored. 

ACKNOWLEDGEMENTS 

Thank you to all key informants from the industry willing to share 

their knowledge and experiences; prosthetists who assisted in the 

recruitment of lower limb prosthetic users and lastly, the prosthetic 

users themselves for sharing their stories about their journey as a 

prosthetic user. 

DECLARATION OF CONFLICTING INTERESTS 

• Bennie Theron: Employee of Ossur South Africa.  

• Surona Visagie: None.  
 

AUTHORS CONTRIBUTION 

• Bennie Theron: Research design; Conceptualizing of the 

study; Data collection; Analysis and interpretation of the data; 

First draft of the manuscript; Manuscript finalization. 

• Surona Visagie: Research design; Conceptualizing of the 

study; Analysis and interpretation of the data; Feedback on 

drafts of the manuscript. 
 

SOURCES OF SUPPORT 

None.  

REFERENCES 

1.Buetow SA, Martínez-Martín P, McCormack B. Ultrabilitation: 

Beyond recovery-oriented rehabilitation. Disabil Rehabil. 2019; 

41(6):740-745. DOI: 10.1080/09638288.2017.1406997 

2.Wyss D, Lindsay S, Cleghorn WL, Andrysek J. Priorities in lower 

limb prosthetic service delivery based on an international survey of 

prosthetists in low-and high-income countries. Prosthet Orthot Int. 

2015; 39(2):102-11. DOI: 10.1177/0309364613513824  

3.Statistical release P0301.4 [Internet]. Census 2022, Statistic 

South Africa. 2023; [cited 2024 Dec 11]. Available from: 

https://census.statssa.gov.za/assets/documents/2022/P03014_Ce

nsus_2022_Statistical_Release.pdf 

4.Manickum P, Ramklass SS, Madiba TE. A five-year audit of lower 

limb amputations below the knee and rehabilitation outcomes: The 

Durban experience. JEMDSA. 2019; 24(2):41-5. DOI: 

10.1080/16089677.2018.1553378 

5.Fisher K, Hanspal RS, Marks L. Return to work after lower limb 

amputation. Int J Rehabil Res. 2003; 26(1):51-6. DOI: 

10.1097/00004356-200303000-00007 

6.Donaghy AC, Morgan SJ, Kaufman GE, Morgenroth DC. Team 

approach to prosthetic prescription decision-making. Curr Phys 

Med Rehabil Rep. 2020; 8:386–395. DOI: 10.1007/s40141-020-

00289-x 

7.Boone DA. The economic value of mobility with a prosthesis. J 

Prosthet Orthot. 2019;31(1S):32-36. DOI: 10.1097/JPO. 

0000000000000231 

8.Geertzen J, van der Linde H, Rosenbrand K, Conradi M, Deckers 

J, Koning J, et al. Dutch evidence-based guidelines for amputation 

and prosthetics of the lower extremity: Rehabilitation process and 

prosthetics. Part 2. Prosthet Orthot Int. 2015;39(5):361-71. DOI: 

10.1177/0309364614542725 

9.Liu H, Chen C, Hanson M, Chaturvedi R, Mattke S, Hillestad RJ. 

Economic value of advanced transfemoral prosthetics [internet]. 

California: RAND. 2017; [cited 2024 Dec 11]. Available from: 

https://www.rand.org/pubs/research_reports/RR2096.html 

10.Kannenberg A, Seidinger S. Health economics: The perspective 

of a prosthetic manufacturer. J Prosthet Orthot. 2019;31(1S):49-54. 

DOI: 10.1097/JPO.0000000000000234 

11.Graham B. Clinical practice guidelines: What are they and how 

should they be disseminated? Hand Clin. 2014;30(3):361-5. DOI: 

10.1016/j.hcl.2014.04.007 

12.Webster JB, Crunkhorn A, Sall J, Highsmith MJ, Pruziner A, 

Randolph BJ. Clinical practice guidelines for the rehabilitation of 

lower limb amputation: An update from the Department of Veterans 

Affairs and Department of Defense. Am J Phys Med Rehabil. 

2019;98(9):820-829. DOI: 10.1097/PHM.0000000000001213 

13.Federici S, Scherer MJ, Borsci S. An ideal model of an assistive 

technology assessment and delivery process. Technol Disabil. 

2014;26(1):27-38. DOI: 10.3233/TAD-140402 

14.Brouwers MC, Kho ME, Browman GP, Clancy C, Fairey S, 

Fletcher RH, et al. AGREE II: Aadvancing guideline development, 

reporting and evaluation in health care. Can Med Assoc J. 

2010;182(18):E839-42. DOI: 10.1503/cmaj.090449 

15.Sadeghi-Demneh E, Forghany S, Onmanee P, Trinler U, Dillon 

MP, Baker R. The influence of standards and clinical guidelines on 

prosthetic and orthotic service quality: A scoping review. Disabil 

Rehabil. 2018;40(20):2458-65. DOI: 10.1080/09638288.2017. 

1335802 

16.Department of employment and labor. Prosthetic and Orthotics 

Gazette 2024 [Internet]. Government Gazette of the Republic of 

South Africa. 2024; [cited 2024 Dec 11]. Available from:  

https://www.coidlink.co.za/Downloads/Tariffs/2024/Orthotics%20a

nd%20Prosthetics.pdf 

17.Sibbald SL, Paciocco S, Fournie M, Van Asseldonk R, Scurr T. 

Continuing to enhance the quality of case study methodology in 

health services research. Can J Health Leaders. 2021;34(5):291-6. 

DOI: 10.1177/08404704211028857 

18.Road Accident Fund Act 56 of 1996 of the Republic of South 

Africa [Internet]. Government of South Africa. 1996;  

[cited 2024 Dec 11]. Available from: 

https://www.gov.za/sites/default/files/gcis_document/201409/act5

6of1996.pdf 

19.Road Accident Fund Act, No. 56 of 1996 [Internet]. Government 

of South Africa. 1996; [cited 2024 Dec 11]. Available from:  
https://www.gov.za/sites/default/files/gcis_document/201409/act5

6of1996.pdf 

20.Compensation for Occupational Injuries and Diseases Act 130 

of 1993 [Internet]. Government of South Africa. 1993;  

[cited 2024 Dec 11]. Available from:  

https://www.gov.za/sites/default/files/gcis_document/201409/act1

30of1993.pdf 

21.Compensation for Occupational Injuries and Diseases Act 61 of 

1997 [Internet]. Government of South Africa.1997; 

https://doi.org/10.33137/cpoj.v7i2.44450
https://census.statssa.gov.za/assets/documents/2022/P03014_Census_2022_Statistical_Release.pdf
https://census.statssa.gov.za/assets/documents/2022/P03014_Census_2022_Statistical_Release.pdf
https://www.rand.org/pubs/research_reports/RR2096.html
https://www.coidlink.co.za/Downloads/Tariffs/2024/Orthotics%20and%20Prosthetics.pdf
https://www.coidlink.co.za/Downloads/Tariffs/2024/Orthotics%20and%20Prosthetics.pdf
https://www.gov.za/sites/default/files/gcis_document/201409/act56of1996.pdf
https://www.gov.za/sites/default/files/gcis_document/201409/act56of1996.pdf
https://www.gov.za/sites/default/files/gcis_document/201409/act56of1996.pdf
https://www.gov.za/sites/default/files/gcis_document/201409/act56of1996.pdf
https://www.gov.za/sites/default/files/gcis_document/201409/act130of1993.pdf
https://www.gov.za/sites/default/files/gcis_document/201409/act130of1993.pdf


 

12 

Theron B, Visagie S. Exploring the need for lower limb prosthetic guidelines in South Africa's private healthcare sector. Canadian Prosthetics & Orthotics Journal. 
2024; Volume 7, Issue 2, No. 8. Https://doi.org/10.33137/cpoj.v7i2.44450 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X THE NEED FOR PROSTHETIC GUIDELINES IN SOUTH AFRICA'S PRIVATE HEALTHCARE 

Theron B and Visagie S, 2024 

 [cited 2024 Dec 11]. Available from:    

https://www.gov.za/sites/default/files/gcis_document/201409/a61-

97.pdf 

22.Medical Schemes Act 131 of 1998 [Internet]. Government of 

South Africa. 1998; [cited 2024 Dec 11]. Available from: 

https://www.gov.za/sites/default/files/gcis_document/201409/a131

-98.pdf 

23.Medical Schemes Act 131 of 1998 [Internet]. Government of 

South Africa. Government of South Africa. 2004;  

[cited 2024 Dec 11]. Available from: 

https://www.medicalschemes.com/files/Acts%20and%20Regulatio

ns/MSREGS19July2004.pdf 

24.What are prescribed minimum benefits [Internet]. Council of 

Medical Schemes. 2021; [cited 2024 Dec 11]. Available from: 

https://www.medicalschemes.co.za/resources/pmb/ 

25.CMScript 2-2023 Amputations [Internet]. Council of medical 

schemes. 2023; [cited 2024 Dec 11]. Available from: 

https://www.medicalschemes.co.za/wpfd_file/cmscript-2-2023-

amputations/ 

26.Etikan I, Musa SA, Alkassim RS. Comparison of convenience 

sampling and purposive sampling. Am J Theor Appl Stat. 

2016;5(1):1-4. DOI: 10.11648/j.ajtas.20160501.11 

27.Appraisal of guidelines for research and evaluation II [Internet]. 
AGREE next steps consortium. 2017; [cited 2024 Dec 11]. 

Available from: https://www.agreetrust.org/wp-

content/uploads/2017/12/AGREE-II-Users-Manual-and-23-item-

Instrument-2009-Update-2017.pdf 

28.Yan J, Min J, Zhou B. Diagnosis of pheochromocytoma: A 

clinical practice guideline appraisal using AGREE II instrument. J 

Eval Clin Pract. 2013;19(4):626-32. DOI: 10.1111/j.1365-

2753.2012.01873.x 

29.Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, 

Feder G, et al. Development of the AGREE II, part 2: Assessment 

of validity of items and tools to support application. CMAJ. 

2010;182(10):E472-8. DOI: 10.1503/CMAJ.091716 

30.Nowell LS, Norris JM, White DE, Moules NJ. Thematic analysis: 

Striving to meet the trustworthiness criteria. Int J Qual Methods. 

2017;16:1-13. DOI: 10.1177/1609406917733847 

31.Theron BJ. An exploration of the need for lower limb prosthetic 

protocols in the South African private healthcare sector [thesis]. 

Stellenbosch: Stellenbosch University. 2024. Available from: 

https://scholar.sun.ac.za/items/af0fbe14-0e14-49f4-bb21-

3962fd4f951a 

32.Fard B, Persoon S, Jutte PC, Daemen JWHC, Lamprou DAA, 

Hoope WT, et al. Amputation and prosthetics of the lower extremity: 

The 2020 Dutch evidence-based multidisciplinary guideline. 

Prosthet Orthot Int. 2023;47(1):69-80. DOI: 10.1097/PXR. 

0000000000000170 

33.McDonald CL, Kahn A, Hafner BJ, Morgan SJ. Prevalence of 

secondary prosthesis use in lower limb prosthesis users. Disabil 

Rehabil. 2023;1-7. DOI: 10.1080/09638288.2023.2182919 

34.Handy Eone D, Nseme Etouckey E, Essi MJ, Ngo Nyemb TM, 

Ngo Nonga B, Ibrahima F. Satisfaction of patients with amputated 

lower limb wearing external prostheses. Int J Orthop Sci. 

2018;4(1f):368-72. DOI:10.22271/ortho.2018.v4.i1f.52 

35.Hebert JS, Burger H. Return to work following major limb loss. 

In: Schultz IZ, Gatchel RJ, editors. Handbook of return to work: from 

research to practice. Boston, MA: Springer US. 2016;505-517 

36.Griffet J. Amputation and prosthesis fitting in paediatric patients. 

Orthop Traumatol Surg Res. 2016;102(1):S161-75. DOI: 

10.1016/j.otsr.2015.03.020 

37.Schaffalitzky E, Gallagher P, MacLachlan M, Wegener ST. 

Developing consensus on important factors associated with lower 

limb prosthetic prescription and use. Disabil Rehabil. 

2012;34(24):2085-94. DOI: 10.3109/09638288.2012.671885 

 

 

 

 

 

 

 

 

 

 

 

 

https://doi.org/10.33137/cpoj.v7i2.44450
https://www.gov.za/sites/default/files/gcis_document/201409/a61-97.pdf
https://www.gov.za/sites/default/files/gcis_document/201409/a61-97.pdf
https://www.gov.za/sites/default/files/gcis_document/201409/a131-98.pdf
https://www.gov.za/sites/default/files/gcis_document/201409/a131-98.pdf
https://www.medicalschemes.com/files/Acts%20and%20Regulations/MSREGS19July2004.pdf
https://www.medicalschemes.com/files/Acts%20and%20Regulations/MSREGS19July2004.pdf
https://www.medicalschemes.co.za/resources/pmb/
https://www.medicalschemes.co.za/wpfd_file/cmscript-2-2023-amputations/
https://www.medicalschemes.co.za/wpfd_file/cmscript-2-2023-amputations/
https://www.agreetrust.org/wp-content/uploads/2017/12/AGREE-II-Users-Manual-and-23-item-Instrument-2009-Update-2017.pdf
https://www.agreetrust.org/wp-content/uploads/2017/12/AGREE-II-Users-Manual-and-23-item-Instrument-2009-Update-2017.pdf
https://www.agreetrust.org/wp-content/uploads/2017/12/AGREE-II-Users-Manual-and-23-item-Instrument-2009-Update-2017.pdf
https://scholar.sun.ac.za/items/af0fbe14-0e14-49f4-bb21-3962fd4f951a
https://scholar.sun.ac.za/items/af0fbe14-0e14-49f4-bb21-3962fd4f951a

