Global clubfoot report 2013
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Global Clubfoot Report 2013
Produced by Global Clubfoot Initiative, 2014
Vision: ‘A world without disability caused by clubfoot’
Mission: ‘Build global capacity for quality clubfoot treatment and
equitable service provision through advocacy, education and
collaboration.’
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Executive summary Introduction
This report aims to provide a summary of provision of services for clubfoot in low and middle-
income countries (LMIC), and children accessing them, in 2013. This report is produced every two
years by Global Clubfoot Initiative in order to highlight progress and needs for children with
clubfoot around the world and builds on previous summaries in 2009 and 2011.
Methods
Data was collected by standardised survey in November – December 2014. GCI identified and
wrote to all coordinators known to the organisation to be responsible for national and regional
level programmes for clubfoot. This was a total of thirty-two requests for information from fifty-
two countries. Data collected from 2013 included numbers and locations of clinics providing
Ponseti treatment, numbers of children enrolled for Ponseti treatment, numbers starting first foot
abduction brace (FAB) and types and sources of support for programmes.
Results
22 organisations and/or individuals provided data representing 39 countries (28% of all LMIC) and
487 clinics, a 69% response rate by organisations and/or individuals and a 73% response rate by
country. 91% of clinics reported that they were part of a national network of service providers for
clubfoot.
In 2013 a total of 21,515 children were enrolled for Ponseti treatment in 2013 in the 39 countries
that provided data.
86% of these were less than 2 years old at start of treatment
83% of those starting treatment went on to be fitted in their first Foot Abduction Brace
‘Expected cases’ of clubfoot per country were calculated using an incidence rate of 1.2/1000
births.
28% of expected cases were enrolled for treatment across all countries, increased from 19% in
2011.
59% of countries enrolled less than 50% of expected cases for treatment but 23% enrolled
more than 100% of expected cases.
Comparing data for 17 countries where it was available for 2009, 2011 and 2013 showed an
increase in the numbers of children enrolled for treatment of 94% in 2009-2011 and 53% in
2011-2013.
Qualitative data indicated that Ministries of Health provide the majority of direct resources to
programmes including clinic space and staff. External support from international NGOs was also
described as being very important to the functioning of programmes, providing funding for
consumables and organisational aspects of programmes as well as for training of staff.
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Conclusions
More children born with clubfoot in LMIC are accessing Ponseti treatment each year and great
progress has been made globally. However, in LMIC the majority of children born with clubfoot do
not receive treatment and more services providing effective treatment and better access to these
are needed urgently, including for older children with neglected clubfoot.
Recommendations
More provision for clubfoot treatment is needed. Support for clubfoot programmes by international, government and NGO level organisations should be sustained and increased.
Increased access to services must be enabled. This is likely to require local analysis of barriers and facilitators to access, with interventions based on these.
Low adherence with long-term Foot Abduction Bracing must be addressed. Analysis of reasons for drop-out, and creative solutions to enable adherence are needed.
Monitoring and evaluation systems must be improved and utilised to show long term outcomes of treatment and enable monitoring of quality of treatment.
Strategies to address neglected clubfoot should be developed and implemented.
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Global Clubfoot Report 2013
Introduction Clubfoot affects around 160-200,000 children born each year with 80% of these in low and middle-income
countries (LMIC). Also known as Congenital Talipes Equinovarus (CTEV), clubfoot is a congenital condition
that, in up to 95% of cases, can be treated successfully using a largely non-surgical technique: the Ponseti
method of treatment. Treatment is most effective if initiated early, ideally during infancy, but there are
now numerous reports of older children being treated using the Ponseti technique.
The Ponseti method is increasingly accepted as the treatment of choice for clubfoot, replacing surgical and
conservative techniques which were previously more widely used. Long-term outcome studies show
superior results from the Ponseti technique. It is also more cost effective, less invasive and has lower risks
of complications than surgical treatments. As such, it is an ideal solution for low resource settings.
In recent decades, the Ponseti method has spread around the world and is used in many LMIC. Each year
new programmes are established for identifying and treating children born with clubfoot. Many countries
have established nationally coordinated programmes with the support of local or international NGOs in
order to reach as many children as possible. Global Clubfoot Initiative, through this report, provides a
‘global overview’ of provision of services for clubfoot and the children accessing them in LMIC. This enables
the charting of global progress and need, and aids in planning future services.
Background Three previous pieces of work provide baseline data on global clubfoot services and treatment: (1) a report
on a 2007-2009 10 country collaborative initiative; (2) a report on 20 countries in 2009 and; (3) a previous
‘global snapshot’ report using data from 2011. GCI aims to update this data every 2 years and the aims of
collecting this data are:
To capture and collate data in order to estimate how much of the need for services for children
born with clubfoot is being met globally
To map what services are available for children with clubfoot in LMIC and who these are provided
by
To enable sharing of information between organisations and individuals involved in providing
treatment for children with clubfoot
Methods In October to November 2014, GCI identified and wrote to all coordinators known to the organisation to be
responsible for national and regional level programmes that provide services for clubfoot. Each was asked
to provide information for the purposes of analysis. This was a total of thirty-two requests for information
from fifty-two countries. Data was self-reported by programme coordinators using a standardised data
collection form.
Data requested for 2013 included:
Numbers and locations of clinics providing services for children with clubfoot
Total number of children up to age 15 starting Ponseti treatment
o Ages of children starting treatment
Total number of children starting Foot Abduction Braces (FABs)
Total number of children completing 2 years of FAB
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Types of support available for clubfoot services and from which providers
For the purposes of this report the majority of data was collected from NGOs that were partner
organisations of GCI, from contacts provided by them and from other organisations we were aware of that
provide clubfoot services. This was not meant to exclude those that were not part of GCI but reflected the
capacity within GCI to carry out this survey and also the willingness and ability of other stakeholders to
collect and share information.
Those who replied were a mixture of:
International NGOs; many of whom support national programmes for clubfoot in multiple countries
Regional NGOs
Country level NGOs
Individual doctors or practitioners working on a regional or country level
A full list of respondents can be found in Appendix one.
Where two or more organisations were working in the same country they were asked to clarify whether the
data they provided was likely to overlap and any duplicated data was corrected.
Results
Clubfoot data results
Thirty-two organisations and/or individuals, known to be working in fifty-two countries were contacted to
provide data. Of those, twenty-two organisations and/or individuals provided data representing thirty-nine
countries and 487 clinics, a 69% response rate by organisations and/or individuals and 73% response rate
by country.
Number of children enrolled for treatment by country, 2013
Continent Country Number of children enrolled
for treatment 2013
Africa Botswana 48
Africa Burundi 265
Africa DR Congo 634
Africa Eritrea 95
Africa Ethiopia 1303
Africa Ghana 1149
Africa Kenya 1096
Africa Madagascar 155
Africa Malawi 908
Africa Mozambique 195
Africa Namibia 70
Africa Niger 254
Africa Rwanda 670
Africa Sierra Leone 109
Africa South Africa 540
Africa Tanzania 42
Africa Togo 147
Africa Uganda 377*
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Africa Zambia 611
AFRICA TOTAL 8,668
Asia Afghanistan 695
Asia Bangladesh 4040
Asia Burma 244
Asia Cambodia 151
Asia India 4238
Asia Laos 118
Asia Pakistan 806
Asia Philippines 37
Asia Vietnam 348
Asia Yemen 122
ASIA TOTAL 10,799
Oceania Papua New Guinea 3
Oceania Solomon Islands 22
OCEANIA TOTAL 25
South America Brazil 142
South America Dominican Republic 303
South America Ecuador 89
South America El Salvador 187
South America Haiti 374
South America Honduras 165
South America Mexico 533
South America Nicaragua 230
SOUTH AMERICA TOTAL 2,023
GRAND TOTAL 21,515
*Known to be an incomplete data set
A total of 21,515 children were enrolled for treatment in 2013 for the 39 countries that provided data. The
39 countries included make up 28% of the total 139 low and middle-income countries identified by the
World Bank. Across all 139 countries, an estimated 168,380 children were born with clubfoot in 2013. This
survey has therefore captured data on 13% of all children born with clubfoot in LMIC in 2013.
For three countries, Chad, The Seychelles and Sri Lanka, surveys were returned with no, or minimal,
numerical data and as such have been excluded from this report. These responses indicated some
provision of Ponseti services in The Seychelles and Sri Lanka, but none in Chad.
The survey broke down the numbers of children enrolled for treatment into five age categories and
separated them by continent in order to gain some understanding of the age at which treatment is being
sought and started. This break down and percentages are presented in the table below although it should
be noted that this represents a subset of the data (55% of total enrolled children) as not all returned data
forms contained information on age of enrolment.
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Children enrolled for treatment by age at start of treatment, 2013
Continent 0-1 years 1-2 years 3-5 years 5-10 years 10-15 years
Africa 3867 1338 139 45 1
Asia 3555 1058 371 155 85
Oceania 19 5 0 0 1
South America 744 145 154 78 20
TOTAL 8185 2546 664 278 107
Percentage of Total
66% 20% 5% 2% 1%
Expected number of cases For each country, the expected number of cases was calculated using the following formulae:
(Total number of babies born*/1000) x 1.2** = Expected number of babies with club foot * Total number of babies born calculated using CIA Fact book Data for 20131 ** 1/2/1000 is the most widely accepted estimate of the incidence of clubfoot worldwide
The data for percentage of expected cases enrolled by country is included as Appendix 2.
Overall across the 39 countries that provided data the percentage of expected cases enrolled was 28%, a
10% increase from 2011. Several countries enrolled more than 100% of expected cases.
In order to measure the reach of treatment in each country we broke the percentage of expected cases
enrolled into treatment into five groups: 0-24%, 25-50%, 51-75%, 76-100%, and one group of >100% to
address those countries who had enrolled more children than the estimated number of cases.
Across the 39 countries just over a third (14) had enrolled between 0-24% of the expected cases in 2013.
This decreases steadily up to 100% at which point 9 countries had enrolled more children into treatment
than the estimated number of cases of clubfoot. See the table below for a graphical representation.
It should be noted that there are confounding factors that may exaggerate the measurement of the reach
of treatment in each country, specifically regarding age of enrolment to treatment. As seen above, total
numbers of children enrolled span a range of 15 years with 37% enrolled after 1 year of age. The expected
numbers of cases of clubfoot, however, represent the number of cases of expected clubfoot among
children born in 2013. Given the incomplete age data for all countries, measurement of the reach of
treatment used total numbers of children enrolled as a percentage of expected cases, thus extending
beyond just those born in 2013. It is therefore likely that percentage reach of treatment is lower for each
country. For those where it appears that coverage exceeds 100% of expected cases this is partially
attributable to the enrolment of older children needing treatment, something to highlight in itself given the
large back-log of untreated clubfoot across all LMIC. Other confounding factors include migration, medical
tourism and the incidence rate used: 1.2/1000. Although this is the most commonly used global estimate,
studies in some Sub-Saharan and Asian countries have found incidence rates of 2-3/1000.
1 Accessed from: https://www.cia.gov/library/publications/download/download-2013/index.html
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Appendix 3 shows expected cases per clinic per population for each country. Regarding number of clinics
per estimated cases of clubfoot there was a wide variety across data sets and countries. The highest
number of cases per clinic were found to be in Brazil and Pakistan (however, for both of these countries we
are aware that numerous providers of clubfoot services did not submit data to this survey), while the
lowest number of cases per clinic was the Solomon Islands.
2013 data compared to previous years Data on numbers of children enrolled for treatment were also collected for 2009 and 2011. The table
below shows the numbers of children treated in each of the countries surveyed where data was also
available for 2009 and 2011.
Continent Country 2009 2011 2013
Africa DR Congo 203 343 634
Africa Ethiopia 616 753 1,303
Africa Ghana 282 710 1,149
Africa Kenya 691 680 1,096
Africa Malawi 590 843 908
Africa Niger 17 75 254
Africa Rwanda 554 501 670
Africa Uganda 733 718 377
Africa Zambia 434 494 611
Asia Afghanistan 78 653 695
Asia Bangladesh 181 2,631 4,040
Asia Cambodia 203 124 151
Asia India 203 2,003 4,238
Asia Laos 78 157 118
South America Dominican Republic 383 179 165
South America Haiti 267 137 374
South America Honduras 203 109 165
TOTALS 5716 11110 16948
0
2
4
6
8
10
12
14
16
0-24% 25-50% 51-75% 76-100% <100%
Number of Countries by Percentage Group of Expected Cases of Clubfoot Enrolled for Treatment
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For the 17 countries where data on numbers of children enrolled were available for all three years (2009,
2011 and 2013) the total number enrolled for treatment has seen a 160% increase since data was first
collected in 2009. The greatest increases have been in Bangladesh, Niger, India and Afghanistan.
The largest increase was between the first two data collections (2009-2011) where data shows a
percentage increase of 94%. Between the last two data collections the percentage increase is much smaller
at 53%. This could be partly due to the incomplete data set for Uganda, which shows an unexpected
decrease in the number of children enrolled in 2013. It is worth noting that the greatest increases since the
last round of data collection have been in Niger, India, Haiti and DR Congo.
Numbers of children enrolled for treatment 2009-2013
Foot Abduction Brace use Use of a foot abduction brace (FAB) is an essential part of the Ponseti treatment process for individuals
with clubfoot. FAB treatment maintains correction of the clubfoot and prevents relapse. Braces can be
produced at low cost using widely available materials. The use of FAB treatment was also included as part
of the data collection form and analysed but there were numerous countries that, for whatever reason,
were unable to provide concise numbers of progression to FAB treatment. Measuring the number of
children receiving their first FAB is an indication of: (1) How many feet were sufficiently corrected during
the manipulation and casting phase to be fitted with a FAB; (2) How many children drop out of treatment
during this phase, and (3) availability of FABs.
0 1000 2000 3000 4000 5000
2009
2011
2013
Number of Children Enrolled for Treatment
Honduras
Haiti
DominicanRepublicLaos
India
Cambodia
Bangladesh
Afghanistan
Zambia
Uganda
Rwanda
Niger
Malawi
Kenya
Ghana
Ethiopia
DR Congo
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For the countries that provided data (57% of the full data-set), 83% of children enrolled for treatment went
on to be fitted with their first FAB. This could indicate a drop-out rate of 17% of children during the
manipulation and casting phase, and it is certainly likely that there would be some drop out during this time
with potential confounding factors being:
A steep rise in the numbers of cases during the course of a year
Incomplete data sets
Country Total Enrolled Total to Start Bracing 2013 Percentage of cases to
start FAB 2013
Botswana 48 - -
Burundi 265 161 61%
DR Congo 634 555 88%
Eritrea 95 72 76%
Ethiopia 1,303 1,422 109%
Ghana 1,149 907 79%
Kenya 1,096 847 77%
Madagascar 155 145 94%
Malawi 908 1,197 132%
Mozambique 195 107 55%
Namibia 70 - -
Niger 254 195 77%
Rwanda 670 601 90%
Sierra Leone 109 - -
South Africa 540 - -
Tanzania 42 18 43%
Togo 147 121 82%
Uganda 377 179 47%
Zambia 611 879 144%
Afghanistan 695 523 75%
Bangladesh 4,040 2,903 72%
Burma 244 - -
Cambodia 151 - -
India 4,238 - -
Laos 118 78 66%
Pakistan 806 546 68%
Philippines 37 35 95%
Vietnam 348 - -
Yemen 122 27 22%
Papua New Guinea 3 - 0%
Solomon Islands 22 22 100%
Brazil 142 128 90%
Dominican Republic 303 - -
Ecuador 89 39 44%
El Salvador 187 91 49%
Haiti 374 - -
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Honduras 165 - -
Mexico 533 390 73%
Nicaragua 230 182 79%
TOTAL 12,370
With regards to longer term FAB use, participants were asked to provide numbers of children completing
two years in FAB. Very few countries were able to provide this data. From those that did, comparison with
numbers enrolled in 2011, where they were available, showed that 2-year adherence with FAB could be as
low as 40-60%.
Types and Sources of Support to Programmes Of the 487 clinics whose data is represented in this report, 443 (91%) reported that they were part of a
national network.
Data from the majority of respondents provided some relatively thorough information of the type and
source of support provided to clubfoot programmes. Sources of support are seen to be wide and varied
including national and international NGOs, Ministries of Health (MoH) and other government bodies, as
well as other sources such as large business corporations.
Types of support can be roughly divided into 5 umbrella categories:
1) Direct Resources (including staffing, equipment and premises) 2) Funding 3) Training 4) Organisational Support 5) Promotion and Awareness (including referrals)
Given the qualitative nature of the data provided it is not possible to ascertain accurate proportions of the
types of support provided and by whom, but general trends in the source of these different types of
support are certainly apparent.
The majority of support in the form of direct resources comes from MoH and other significant government bodies. This is particularly the case for the provision or staff and clinic premises. NGOs (both national and international) do also provide some direct resources (largely equipment) but this isn’t the focus of their support.
It is the majority of financial and organisational support that comes from international NGOs. Some financial support does also come from MoH or other government bodies and a small amount from local NGOs and other sources such as large business corporations including Toyota Malawi.
Limited explicit information is given as to the source of training support but this might be due to it being included within organisational support for implementing programmes and would therefore be predominantly provided by international NGOs. Even if this is not the case the majority of training support is still indicated to be provided by international NGOs including Ponseti International Association (PIA).
Even less explicit information is given about how programmes are supported to raise awareness and promote clubfoot treatment but where this is mentioned the majority is indicated to be supported by MoH or other government bodies. There are two reported instances of national NGOs providing awareness raising support including the Football Association of Malawi and a children’s charity in the Philippines.
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Discussion In 2013 thirty-nine countries for which data was collected can be seen to have enrolled more than 21,500
children; approximately 28% of expected cases of clubfoot in these countries. This data represents survey
respondents only and it is acknowledged that in many countries there may be individual practitioners or
programmes treating children with clubfoot that were not included in this survey. In Brazil and Pakistan for
instance, both countries with large populations, the numbers collected were relatively low as they came
from one or several regional programmes and we are aware that there are other networks of Ponseti
providers from whom we were not able to collect data. In many other countries, however, particularly
those in Sub-Saharan Africa with low numbers of orthopaedic specialists per population, nationally
coordinated clubfoot programmes do include most, if not all, practitioners providing Ponseti treatment. All
this considered, the true numbers of children enrolled for treatment, both in the thirty-nine countries
featured here and worldwide, are likely to be substantially higher.
Globally, the numbers of cases enrolled for treatment is growing steadily over time, albeit with a drop in
growth rate in 2011-2013 compared with 2009-2011 (this is partly due to known incomplete data sets for 2
countries for 2013). During the same time period the percentage of expected cases enrolled in treatment
across all countries included increased from 19% in 2011 to 28% in 2013. The number of countries
enrolling more than 100% of expected cases increased from 3 in 2011 to 9 in 2013 indicating that in this
time period several country programmes saw increased access to the services offered. These increases in
the percentages of expected cases enrolled are an encouraging finding, indicating that as national
programmes grow and mature more children really are accessing treatment.
Across all countries included in this report, an estimated 72% of expected cases are not accessing
treatment. There is therefore an urgent need to increase efforts to make services accessible to all children
needing it. In addition, many countries do not yet have any documented provision of Ponseti services. Lack
of effective treatment at an appropriate age will almost certainly lead to neglected clubfoot and this
highlights an urgent need for interventions for neglected clubfoot to be further developed.
Just under half of countries (23/39) enrolled less than 50% of expected cases in 2013. This reflects a large
number of new country level initiatives started in 2011 - 2013 and low growth in some countries during the
time period. Low growth in programmes’ reach is likely to be dependent on a wide range of local factors. It
would be beneficial in future for programmes to investigate local barriers and facilitators and to address
these in order that more children could access their services.
Higher numbers of clinics per population appear to have given an advantage in enrolling higher percentages
of expected cases of clubfoot. For those countries enrolling 75% or more of expected cases into treatment
the mean number of clinics/expected cases was 1/40. This increased to 1/310 for those countries enrolling
less than 75%.
It must be noted when discussing expected cases enrolled that 34% of cases enrolled were older than 1
year, whereas ‘expected cases’ were calculated on a yearly basis. Figures and discussion on expected cases
are therefore presented to enable comparison between countries and to provide estimates of programme
coverage rather than as accurate figures on actual cases.
For those countries that were able to provide data on the ages of children at start of treatment, 66%
started under 1 year of age, and 86% under two years of age. As treatment is likely to be most effective
when started early this is a very positive finding. However, it must be noted that the survey asked about
children enrolling for Ponseti treatment only. It is not known whether higher numbers of older children
sought treatment but were either not offered treatment due to their age, or were treated surgically.
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It was also a positive finding that approximately 83% of children enrolling for treatment were fitted with a
first Foot Abduction Brace. This indicates that at least 83% gained adequate correction of the clubfoot
deformity to go into a brace that drop-out during the manipulation and casting phase of treatment was not
more than 17%, and that a first FAB was available to 83%. Whilst a drop-out rate of 17% may seem high
(and could certainly be improved upon) we acknowledge that the countries represented can be very
challenging environments both to work in and for parents to attend treatment regularly. Longer-term data
on FAB wear was not sufficient to draw any firm conclusions as not many countries were able to provide it.
However, indications are that 2-year FAB adherence could be as low as 50%. This is a concerning finding,
given that current recommendations are that children wear FABs until 4-5 years of age in order to prevent
relapse.
Most respondents to the survey gave information on the types and sources of support to programmes.
Qualitative data indicated that Ministries of Health provide the majority of direct resources to programmes
including clinic space and staff. External support was also described as being very important to the
functioning of programmes, providing funding for consumables and organisational aspects of programmes
as well as for training of staff. This public-private partnership appears to function well in enabling clubfoot
programmes to expand their reach year on year.
Data collection for 2013 was easier compared with 2011, with more respondents and all organisations
submitting the data in the format requested, and increasing numbers able to provide a more complete data
set. This shows that systems for monitoring and evaluation are improving and there is increased
willingness amongst respondents to share information.
Limitations As already stated, one of the main limitations of this survey is that, despite our best efforts, data was
collected from a relatively small group of respondents. Data was self-reported and it was not within the
scope of this report to evaluate individual respondents’ data collection methods so we are not able to
guarantee its reliability. It is therefore difficult to base any firm conclusions on the number of children
accessing treatment for clubfoot globally on this data. It does, however, help provide a baseline estimate
for the countries included and a picture of worldwide activity that can be built on in future surveys.
The data set collected was also very basic and was not able to show the exact treatment given or the
outcomes of that treatment. Despite this, it was understood by all submitting data that ‘treatment’ would
be defined as Ponseti method as the treatment of choice but in some cases (especially those of older
children) this may have been supplemented with surgical intervention. We were also not able to collect
data on numbers of children dropping out after initially enrolling for treatment. We are therefore unable
to comment on the outcomes of treatment.
Recommendations More provision for clubfoot treatment is needed. Support for clubfoot programmes by
international, government and NGO level organisations should be sustained and increased.
Increased access to services must be enabled. This is likely to require local analysis of barriers and facilitators to access, with interventions based on these.
Low adherence with long-term Foot Abduction Bracing must be addressed. Analysis of reasons for drop-out, and creative solutions to enable adherence are needed.
Monitoring and evaluation systems must be improved and utilised to show long term outcomes of treatment and enable monitoring of quality of treatment.
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Strategies to address neglected clubfoot should be developed and implemented.
Conclusions The numbers of children accessing Ponseti treatment for clubfoot in LMIC continues to increase. 2013 saw
21,515 children enrolled for Ponseti treatment across 39 countries and 487 clinics. The numbers of
countries offering services for clubfoot through regional or national programmes for clubfoot also
increased, as did the percentage of children accessing these services in several countries. The vast majority
of children enrolled in these programmes are starting treatment at an appropriate age for it to be effective,
and adherence with the manipulation and casting phase of treatment is good at 83%.
Globally, the burden of disability caused by clubfoot remains very high. Even in the countries amongst our
survey respondents with some of the most well organised and supported national programmes in LMIC,
only 28% of expected cases of clubfoot were enrolled for treatment overall. Whilst progress has been
made this still shows an urgent need for services to be made available and accessible to the 72% of children
going untreated each year. Effective interventions for neglected clubfoot in older children must also be a
priority. Further investigation is warranted into individual country-level barriers preventing access to
treatment – and in those countries that are reaching higher percentages into the facilitators of these.
Adherence with treatment in the longer term is another issue that must be measured and addressed and
solutions to the problem of non-adherence shared. Without this as a priority resources spent on treating
children who will ultimately develop a relapse of clubfoot may be wasted and these children will experience
disability that is otherwise largely preventable through the application of a FAB.
It is vital that local and global providers continue to work together towards an end to untreated clubfoot
and to build upon the progress that has already been made.
Data collection, analysis and report written by:
Kristin Childers-Buschle Intern at Anthrologica
Rebecca Ward Global Clubfoot Initiative Programme Officer
Rosalind Owen Global Clubfoot Initiative Programme Manager
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References Ponseti I, Smoley E (1963) Congenital Club Foot: The Results of Treatment. Reprinted in: Clinical
Orthopaedics and Related Research (2009) 467 (5): 1133-1145
Sabtai L, Specht S, Herzenberg J (2014) Worldwide spread of the Ponseti method for clubfoot. World Journal of Orthopaedics 5 (5): 585-590
Global clubfoot report 2013
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Appendices
Appendix 1:
List of survey respondents by country
Continent Country Organisation providing data
Africa Botswana MoH*
Africa Burundi Burundi Clubfoot Programme
Africa DR Congo CURE, East DRCongo
Africa Eritrea -
Africa Ethiopia CURE
Africa Ghana Ghana Clubfoot Programme
Africa Kenya Clubfoot Care for Kenya
Africa Madagascar Public Hospital
Africa Malawi MNCP***
Africa Mozambique MoH*
Africa Namibia MoH*
Africa Niger Niger Clubfoot Programme
Africa Rwanda MoH*
Africa Sierra Leone National Clubfoot Programme
Africa South Africa Department of Health
Africa Tanzania Tanzania Clubfoot Programme, ACT
Africa Togo Toto Clubfoot Programme
Africa Uganda -
Africa Zambia FBO, ZCP, MoH*, Stand Alone
Asia Afghanistan ICRC
Asia Bangladesh MOHFPN**, in private organisation
Asia Cambodia CURE
Asia India CURE
Asia Laos MoH*
Asia Burma -
Asia Pakistan Department of Health
Asia Philippines CBM
Asia Vietnam -
Oceania Solomon Islands MoH*
Oceania Papua New Guinea Cheshire Disability Services
South America Brazil State University of Sao Paulo, City University of Sao Paulo
South America Dominican Republic -
South America Ecuador Junita de Beneficencia, Health Ministry, Patronato System
South America El Salvador Government National Network
South America Haiti CBM
South America Honduras CBM
South America Mexico Health Ministry/IMSS, Red Cross, Baptist Health Ministry
South America Nicaragua UNAN-Leon, Health Ministry, Patronato System
* Ministry of Health ** MOHFPW Ministry of Health and Family Planning Welfare *** MNCP Malawi National Clubfoot Programme
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Appendix 2:
Country level programmes: Percentage of expected cases needing treatment enrolled in 2013
Continent Country Number enrolled
for treatment 2013
Expected number of babies with
clubfoot
Percentage enrolled versus expected cases
Africa Botswana 48 55 87%
Africa Burundi 265 523 51%
Africa DR Congo 634 3293 19%
Africa Eritrea 95 235 40%
Africa Ethiopia 1303 4289 30%
Africa Ghana 1149 959 120%
Africa Kenya 1096 1590 69%
Africa Madagascar 155 911 17%
Africa Malawi 908 805 113%
Africa Mozambique 195 1130 17%
Africa Namibia 70 54 129%
Africa Niger 254 950 27%
Africa Rwanda 670 512 131%
Africa Sierra Leone 109 254 43%
Africa South Africa 540 1116 48%
Africa Tanzania 42 2157 2%
Africa Togo 147 300 49%
Africa Uganda 377 1856 20%
Africa Zambia 611 730 84%
Asia Afghanistan 695 1458 48%
Asia Bangladesh 4040 4334 93%
Asia Burma 244 1251 20%
Asia Cambodia 151 454 33%
Asia India 4238 29651 14%
Asia Laos 118 203 58%
Asia Pakistan 806 5510 15%
Asia Philippines 37 3123 1%
Asia Vietnam 348 1838 19%
Asia Yemen 122 964 13%
Oceania Papua New Guinea 3 196 2%
Oceania Solomon Islands 22 4 587%
South America Brazil 142 3611 4%
South America Dominican Republic 303 236 129%
South America Ecuador 89 356 25%
South America El Salvador 187 125 149%
South America Haiti 374 277 135%
South America Honduras 165 245 67%
South America Mexico 533 2595 21%
South America Nicaragua 230 130 176%
TOTAL 21,515 28%
Global clubfoot report 2013
18
Appendix 3: Estimated cases compared to clinics
Continent Country Estimated cases
Number of
clinics
Estimated number of cases
per clinic
Country population in
2013
Africa Botswana 55 1 55 2,127,825
Africa Burundi 523 6 87 10,888,321
Africa DR Congo 3293 10 329 75,507,308
Africa Eritrea 235 4 59 6,233,682
Africa Ethiopia 4289 32 134 93,877,025
Africa Ghana 959 16 60 25,199,609
Africa Kenya 1590 37 43 44,037,656
Africa Madagascar 911 2 455 22,599,098
Africa Malawi 805 29 28 16,777,547
Africa Mozambique 1130 6 188 24,096,669
Africa Namibia 54 1 54 2,182,852
Africa Niger 950 10 95 16,899,327
Africa Rwanda 512 22 23 12,012,589
Africa Sierra Leone 254 6 42 5,612,685
Africa South Africa 1116 16 70 48,601,098
Africa Tanzania 2157 7 308 48,261,942
Africa Togo 300 7 43 7,154,237
Africa Uganda 1856 6 309 34,758,809
Africa Zambia 730 16 46 14,222,233
Asia Afghanistan 1458 6 243 31,108,077
Asia Bangladesh 4334 49 88 163,654,860
Asia Burma 1251 5 250 55,167,330
Asia India 29651 87 341 1,220,800,359
Asia Cambodia 454 9 50 15,205,539
Asia Laos 203 5 41 6,695,166
Asia Pakistan 5510 4 1377 193,238,868
Asia Philippines 3123 3 1041 105,720,644
Asia Vietnam 1838 21 88 92,477,857
Asia Yemen 964 2 482 25,408,288
Oceania Papua New Guinea 196 1 196 6,431,902
Oceania Solomon Islands 4 1 4 597,248
South America Brazil 3611 2 1805 201,009,622
South America Dominican Republic
236 9 26 10,219,630
South America Ecuador 356 3 119 15,439,429
South America El Salvador 125 5 25 6,108,590
South America Haiti 277 9 31 9,893,934
South America Honduras 245 13 19 8,448,465
South America Mexico 2595 16 162 116,220,947
South America Nicaragua 130 3 43 5,788,531
