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Purpose: The burden of hearing impairment and disability is substantial in the developing world. This review outlines the associated need for amplification devices in low and medium income countries and some of the initiatives that have been taken to improve access to such devices, particularly hearing aids. The main observed barriers to access are listed and possible ways to improve access are considered. Methods: Prevalence estimates for disabling hearing impairment are reviewed and a number of national and international examples of initiatives to facilitate use of hearing assistive devices in low and medium income countries are provided. Technologies that are potentially appropriate for hearing instruments in developing countries are suggested, as well as fitting programs that are more likely to be maintained over the long term. Results: Challenges to successful hearing instrument fitting in low and medium income countries are many. However, some programs point the way to improved access to such devices. Successful hearing aid fitting programs in developing countries have typically combined appropriate technology with a sustainable local support base. Conclusions: With a rising middle class in many developing countries, advances in technology, and ongoing training programs for those involved in amplification fitting, hearing device usage rates may eventually reach parity with those in developed economies. [ABSTRACT FROM AUTHOR]