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Written by Matt Thomson Project Manager at STAND & PhD Candidate at University of Bristol
I’ve just got back from the International Society for Prosthetics and Orthotics congress in Stockholm. It was a whirlwind: technical showcases, policy panels, academic debates, late-night dinners, hallway chats with everyone from component designers to amputee advocates. Some people were there to demo knees, others to talk about socket algorithms or polymer strength. But in the corners where Sub-Saharan Africa and other LMICs came up, a different conversation surfaced, quietly but consistently. Not always labelled as localisation, but always circling questions of power, ownership, and who gets to decide what matters.
That conversation has been part of my life for a while now. I manage programmes for STAND | we walk together, an NGO working on prosthetics and rehabilitation across Africa. I’m also doing a PhD on localisation and assistive technology. I sit in strategy meetings with donors, thinktanks about increasing for the global south through policy or AI, but I also WhatsApp with clinic staff about petrol refunds, flooding and broken phones. I help write grant applications, but I also help translate partner priorities into language donors understand.
I’m not neutral in this. I’m in it, complicit in the systems I question, trying to shift power while operating within structures that were never designed for that. And I know I’m not alone. That’s what made #ISPO2025 so clarifying. You could feel it: the push-pull between ambition and architecture, values and logistics. Everyone wants to do better, but no one’s quite sure how.
This blog isn’t an answer. It’s a reflection: part field note, part snapshot, part autoethnography - on what we’re learning, what we’re getting wrong, and where there might still be space to build something better.
What Everyone Agrees On (But Still Isn’t Happening)
Let’s be honest: not everyone at ISPO was talking about localisation. That’d be weird. Some people were there to demo new knees or launch a new foot design. Others were deep in conversations about polymer strength, socket alignment, remote adjustment apps, or logistics flows. There were researchers from Oslo talking gait mechanics, clinic leads from Nova Scotia sharing patient support strategies, and sales teams hustling their way through the expo hall.
But in the corners of the conference where LMIC work was being discussed; that’s where the localisation conversation kept cropping up. Small start-ups trying to partner with clinics in Uganda. Donors figuring out how to move beyond centralised supply chains. Peer support groups advocating for design input from amputees. NGOs grappling with how to genuinely share decision-making instead of just handing over admin.
There’s a surface-level agreement in those spaces. A shared language that says: yes, decisions should be made closer to the ground. Local actors need funding, autonomy, and voice. But beneath that it’s shaky.
Because while the principle sounds nice, the systems still say otherwise. Funding flows north to south. Procurement flows from manufacturers to consumers. Knowledge flows from “experts” to “field staff.” ISO standards, grant templates, reporting cycles; they’re designed to protect, yes, but they also define what counts as valid. And if you don’t tick those boxes? You’re out. Even if your solution works. Even if it’s better suited to the context.
That’s the contradiction. Everyone I spoke to in those circles knows the system needs to shift. And most of them are trying. But even the best intentions are constrained by the scaffolding we’re all working within.
Roepstorff (2020) calls this “performance”: the staging of participation without shifting power. Boateng (2021) warns that localisation without epistemic redistribution just reinforces the same hierarchies under new labels. And I saw that tension everywhere: in conversations about component design, funding eligibility, clinical autonomy.
It’s not that people are against localisation. It’s that the default settings of the system haven’t caught up. And maybe can’t, without more disruption.
And so the cycle continues: we say the words, nod along, make the case but when it comes time to sign off, it’s often the same people holding the pen.
What Real Localisation Looks Like (and What It Takes to Get There)
When localisation works, it doesn’t feel like strategy. It feels like trust.
In countries where STAND has been around a while (such as Ghana, The Gambia, Uganda) things run a little differently. Not perfectly. But there's a depth to the relationships. We’ve either built teams that live and work where the programmes are, or we’ve formed partnerships strong enough that we can step back from the day-to-day and let others lead. We don’t have to be in every group chat or sign off on every session plan.
But, and this is the bit people often skip, structurally, we still have to be over the budget and the reporting. Donors expect financial accountability, monitoring frameworks, formal documentation. We pass that pressure downstream whether we want to or not. Sometimes we translate between systems. Other times we reproduce them. There’s no clean version of this.
Some partners from East Africa shared experiences of international NGOs who flew in, dropped off bulk donations and left. No rehab plans. No follow-up. No systems. Just a mess for the local clinic to clean up. And sure, those NGOs thought they were helping. But without training, infrastructure, or continuity, the gesture is often more disruptive than supportive.
But here’s the nuance: sustainability often does require some centralisation at the start. A stable supply chain. Oversight. Consistency. You can’t always localise from day one. Sometimes you need scaffolding before you hand things over. The trick is knowing when to loosen the grip and having the courage to actually do it.
Another group talked about a prosthetics programme they’d built over years in West Africa: local production, government collaboration, brilliant clinical outcomes. But when the national health budget priorities shifted, the whole programme collapsed. The international partner had to withdraw. Even though the work was locally led, it was never fully locally resourced. The donor office abroad had been the real engine, even when the faces on the ground weren’t.
That’s the paradox: localisation can be real and fragile at the same time.
Listening to the Quiet Work
Some of the most grounded, powerful work I’ve seen in this field doesn’t come with logos or launch events. It comes from small, underfunded community groups: peer-led networks, volunteer-run initiatives, disability advocates running whatsapp support circles from their bedrooms. People who just quietly do the work. No branding, no metrics. But impact, all the same.
They’re the ones helping people navigate broken health systems. Getting someone from a rural town to a fitting clinic three minibuses away. Translating forms. Chasing referrals. Or just showing up. It’s not “scale”, but it’s solidarity.
These groups rarely get direct funding. Not because they’re not effective, but because they don’t fit. They don’t have finance departments or annual reports. They’re messy and personal and flexible in ways the system isn’t designed to reward. But when you listen, they’re often the ones asking the most relevant questions.
At ISPO2025, I heard a lot about clinical outcomes, fitting ratios, new materials. All important. But over coffee or in the hallways, there was also frustration: the kind that slips out sideways in passing remarks. Like how multimillion-pound investments go into robotic limbs that cost £100,000 each, while entire countries in Sub-Saharan Africa operate on P&O budgets smaller than the cost of a single European prosthesis. From a commercial standpoint, sure, it makes sense. But morally? Strategically? It raises real questions. If you’re innovating for the global market, why leave out most of the globe?
That’s what gets to me. NGO, dozens of start-ups and social enterprises, are doing the slow, gritty work of building markets where none exist yet. In some countries, there’s one prosthetist for the whole population. Clinics can’t afford international products and rely almost entirely on aid. But if we get this right with some funding, patient capital, and long-term partnerships we could open up new industries. Grow local talent. Attract investment. Change the model.
Still, that future isn’t guaranteed. The energy is there. The innovation is there. But the global system isn’t yet structured to value the kind of decentralised, patient work that could make it happen.
And yet… I don’t think the answer is abandoning the system. I think it’s bending it. Making space. Letting relationships lead the framework not the other way around.
Because if we’re not building around the people who are already doing the work, what are we even doing?
Working Within the Constraints
Here’s the thing I’ve had to admit, to myself, again and again: we replicate the system we say we want to change. Even when we don’t want to. Even when we know better.
Even when we try to do things differently. We work with partners we trust, we step back when we can, we co-design where it makes sense. But we also send budget templates. We chase reports. We log outputs and write end-of-year summaries that filter out the nuance and the mess.
That’s not because we’re hypocrites. It’s because the system requires it. Donors want value for money. They want indicators and targets and clean data. And we pass those expectations downstream, not always because we believe in them, but because that’s how we keep the lights on. That’s how we get funding in the first place. This doesn’t make us villains. But it does make us part of the problem.
At ISPO2025, it was clear that others feel this too — the tension between what we want to do and what we’re allowed to do. Some clinic directors said they’ve had to turn down innovative ideas because they couldn’t be measured neatly enough for funders. Others admitted they’ve adapted programmes after funding approval just to reflect what was actually needed, then retrofitted the logframe. Everyone’s navigating, bending, just making it work, not out of dishonesty, but out of necessity.
We talk a lot about localisation. But if we’re honest, a lot of what gets labelled “localisation” is still shaped by the same top-down architectures. Local actors are “consulted” but don’t hold the pen. They’re “empowered” within boundaries already drawn. It’s participation, but only of a certain kind. Roepstorff et al. (2020) call this “imposed participation” - where involvement is expected, but decision-making isn’t on the table.
I’ve been guilty of this too. Asking partners for input, knowing full well we didn’t have the flexibility to act on it. Calling something “co-designed” when the parameters were already set. It's not about intention - it's about structure. And until we reckon with that, we’ll keep reproducing the very dynamics we’re trying to dismantle.
So what do we do? I don’t have a perfect answer. But I’m learning to start by naming it. By being honest about the constraints, instead of pretending they don’t exist. By making room, wherever possible, for context, contradiction, and co-creation, even if that means things move slower or feel messier.
Because if we can’t be honest about the system we’re working in, we’ve got no chance of changing it.
Where We’re Still Learning
We’ve made progress, sure, but we’re nowhere near where we need to be. Some things at STAND are working. We’ve got international staff or fund the salaries of grassroots partners. We’ve shifted decision-making in real ways - not everywhere, and not perfectly, but more than just symbolic. Sometimes our partners lead implementation entirely. Sometimes they design the programmes from scratch. Sometimes we’re just in the background, backing them up.
But structurally, we’re still upstream. We still hold the purse strings. We still set the deadlines and translate the messy reality into donor speak. That’s not nothing: it’s power. Even when we try to hand it over, there are limits. Because budgets still need to add up. Because audits are still audits. Because we’re all operating in a system that wasn’t designed for flexibility, and certainly not for equity.
And when things go wrong, which they sometimes do, it’s still usually us who decides what “wrong” means.
There’s also the reality that trust takes time. In places where we’ve been for years, it’s easier. We know the context, we’ve messed up and repaired, we’ve got shared rhythms. But in newer partnerships, everything’s more delicate. I’ve seen what happens when we rush that, when we assume alignment that isn’t there, or try to “empower” without building the relationships first. It backfires.
I’ve had many times where a funder has come to us, offering to fund a specific programme, and I’ve done my best to make it work and fit our local partners into the whims of where the money comes from — because it can fund our other good stuff as well. But now, I try to ask better questions:
- Who actually defined the scope of this project?
- What are we assuming is the “problem” here and whose assumptions are those?
- What’s going to be left when we’re gone?
These questions don’t fix everything, but they help. They make us pause, reflect, stretch out that uncomfortable silence long enough to realise when we’re steamrolling.
We’re also getting better (slowly) at sharing failure. Not just in internal reviews or M&E meetings, but out loud. In sector spaces, in webinars, in conversations with funders. Saying: “This didn’t work. Here’s why. Here’s what we learned.” It’s exposing. But it’s necessary.
At ISPO this year, one of the moments that stayed with me was a presentation from a university research team, they’d trialled a low-cost solution for part of a prosthetic leg build. First tested in a high-resource setting, then moved into a low-resource context for field trials. The result? Some patients experienced breakages: actual failures in real limbs. The researchers, to their credit, owned up to it. They said plainly: “We shouldn’t have tested this here. The risks were too high. The power imbalances too stark.” It was meant as a lesson - and it was brave. But even so, they got pushback. Some were uncomfortable, maybe even angered by it. But if we’re not in a place where we can hear mistakes like that, really hear them - and make space for them to be shared without punishment, then what are we doing? Sanitised narratives don’t move us forward. Honesty does.
So yeah, we’re still learning. And I hope we always are.
Not a Destination, But a Direction
Localisation isn’t a badge to earn. It’s not a goalpost we pass and then we’re done. It’s a direction. A practice. A set of small, constant, sometimes contradictory decisions we make every day: who we hire, how we budget, what gets compromised, what doesn’t.
And that direction asks more from us than just policy tweaks. It asks for a deep shift in how we think about power, failure, relationships, and accountability. It means being reflexive enough to say, “this model doesn’t work anymore,” and bold enough to try something else even when the spreadsheet doesn’t like it. Even when the donor doesn’t get it. Even when we’re not sure it’ll land.
It’s hard. It’s slow. And it’s not always tidy.
But there’s something hopeful in how alive the conversation is. At ISPO 2025, I was in rooms with policymakers, engineers, clinicians, NGOs, start-ups, amputee-led networks, academics, manufacturers and this stuff was on the table. Not for everyone, not constantly, but it was there. People spoke frankly about colonial legacies, power imbalances, dependency, gatekeeping, and what it would take to build something better. Not perfect; better.
There’s momentum. There’s friction too. But friction means movement. And coming up against walls means we are trying to change the boundaries.
The truth is, those of us already in the system, working within INGOs, managing grants, writing reports, we’re complicit. That’s unavoidable. But being complicit doesn’t mean being powerless. It means we’re close enough to change how things are done. To open space. To shift priorities. To challenge assumptions - even our own.
So no, we don’t always get it right. I don’t always get it right. But every time we ask better questions, every time we centre people not paperwork, every time we share the mic; that’s a step. Not a destination. But a direction worth walking in.
Let’s just keep walking. Together.
