JCPSLP Vol 18 No 3 2016

119 / 156

JCPSLP Volume 18, Number 3 2016 117
authors are aware of six practising SLPs in Ghana. Half are
Ghanaian nationals, all were trained outside of Ghana and
all are based in the capital city. There are no free speech-
language pathology (SLP) services in the country and the
National Health Insurance Scheme does not subsidise
speech-language pathology (National Health Insurance
Scheme, 2016). Clients frequently report travelling for many
hours to attend services.
As in many majority-world nations, people with
communication difficulties (PWCD) in Ghana require
development of a range of rehabilitation services and
supports, of which SLP is only one element (Wickenden,
2013). There are a range of people working with PWCD
who provide important contributions to rehabilitation.
Teachers, teaching assistants, therapists, therapy/
educational aides (known locally as facilitators), community-
based rehabilitation (CBR) workers, nurses, carers and
parents all provide important work in this arena and are
indispensable in providing a network of services and
support for PWCD.
While every majority-world country and context differs,
there are frequently common themes associated with
service provision challenges. Often, there is a small
workforce, no SLP training programs (Fagan & Jacobs,
2009), little professional development, and limited training
for CBR or mid-tier workers in communication disability
(World Bank & World Health Organization, 2011). Where
SLP services exist, payment is often required and insurance
cover for SLP is extremely limited. The community may
have limited awareness of communication disability
(Wickenden, 2013) and differing beliefs about the causes of
communication disability (Ndung’u & Kinyua, 2009).
The insider perspective
Individuals frequently view a shared experience in differing
ways, particularly when their context and cultural
backgrounds differ (Nixon et al., 2015). Alternative
perspectives can result in tensions within relationships that
are frequently unarticulated (Nixon et al. 2015). One aim of
this paper is to encourage readers to attempt to view
visiting partnerships through the lens of an ‘insider” –
someone who may be there before minority-world SLPs
arrive, support them during their work, then continues on
after they leave – to enable more critical reflection of
sustainable relationships.
To reflect on issues around partnerships for sustainable
service development using an insider perspective, we
encourage readers to consider a fictional vignette (Box A).
This example offers the chance to reflect on some of the
many issues that are present when an “outsider” visits a
local service. Navigating relationships between services
or clinicians in the majority and minority worlds can be
complex, yet undoubtedly globalisation has resulted in
dramatically more opportunities for collaboration (Friedman,
2006). With this edition of the journal focused on the
theme “Minority-world SLPs in majority-world contexts”,
it is important to reflect on what contributes to effective
partnerships between majority- and minority-world services.
How can minority-world SLPs
assist development of sustainable
services for PWCD in majority-
world countries?
In the spirit of a local proverb in Akan “Nyansa nne eti
kromu” [translation: Wisdom is not the preserve of one
Josephine
Ohenewa
Bampoe (top),
and Nana Akua
Owusu
Box A: Turning the tables: Insiders and outsiders –
an example
Imagine that you are one of two SLPs and two
assistants working in a government clinic in remote
Australia. Budget cuts mean equipment is dated or
non-existent. You offer services across a huge
geographical area to a large population. A skilled and
experienced speech-language pathologist from a
well-resourced service in Africa offers to volunteer for 3
months. As services are stretched to the limit in your
clinic, you are excited to have someone to help you
improve services. In the weeks prior to arrival, you
exchange emails and Skype calls. You help him/her to
organise accommodation. You advise on transport,
safety, the weather, the health system, and you collect
the volunteer from the airport.
Your new colleague is generous in sharing their
knowledge. Your service enhances training and
expands clinical services. You are working on
interesting projects and feel inspired by the rich clinical
discussions. But there are challenges. The visiting
practitioner struggles to understand how things
happen in your context and seems to have an agenda
for what is required, which doesn’t match your view
of the need. Given the visitor is more experienced,
volunteering their time, and contributing resources,
it is hard to argue. At a service level, there are small
issues. The visiting practitioner has trouble with the
language, so cannot work independently. Clients often
don’t understand what he/she means when explaining
things, but are too polite to mention it. There are
awkward moments – such as when the visiting
practitioner tells clients to focus on giving instructions
to their children rather than engaging in reciprocal
play, or hints that the type of therapy you are offering
may not be best practice. The visiting practitioner
doesn’t know how to do the things that are considered
important in your context (e.g., making sure certain
families have transport money or helping to find a
school that will take their child). You understand that it
is simply a difference to how things are done in Africa.
The visiting practitioner helps to train the assistants
in a particular type of therapy. Everyone is excited
about skill development. It is wonderful to make the
connection, but all the things you need to organise for
the visitor are added on top of your usual workload.
The visiting practitioner returns to Africa and you are
back juggling the demands of service provision to
desperate clients, and the many other needs (e.g.,
awareness raising, training others, special projects to
improve services, prevention work, and trying to build
a profession). The visiting practitioner stays in touch for
some months and sends some invaluable resources.
The assistants need further support in adapting their
new programs to the culture, and you struggle to
support them and maintain your other work. After two
months, another NGO from Africa offers to assist in the
development of autism services and would like your
involvement. You feel like you are still playing catch-up
with your usual work. What is your response?