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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?