Communication disability service structure

Services in Minority World countries are structured in different ways in order to try to meet the needs of PWCD. SLT is one service for PWCD, which is more commonplace in Minority World countries than Majority World countries (Wylie et al., 2016). In Majority World countries, typically the first services for PWCD use a medical model. Developing from this, SLT services are often hospital- based and part of departments such as ENT.

Majority World countries often have many challenges in developing services for PWCD. One problem with applying specialist healthcare knowledge in Majority World countries is that, even where sufficient facilities and knowledge enable accurate diagnosis of communication disabilities, effective treatments are still often beyond the financial means of PWCD. Wirz and Lichtig (1998) examined the diagnosis and treatment of audiological impairments in Sao Paulo, Brazil. Though free-to-access assessment clinics existed, they found the majority of hearing impaired children could still not afford hearing aids. Even with a number of programmes focused on the distribution of hearing aids from Minority World countries to Majority World countries, supply is still unable to match demand, meaning that — even with accurate diagnoses — a large proportion of CDs still go untreated.

Even where treatment is available, such as in Thailand, there are many reasons PWCD do not access such support. Prathanee et al. (2010) found that Thai people with cleft lip and palate may not be referred to SLT services for three reasons: a lack of awareness of the support available; a belief that surgical intervention will solve all related difficulties; and prohibitive travel costs. Even in South Africa, which has a relatively high number of SLTs for a Majority World country, Jordaan and Yelland (2003) suggested that a dearth of sufficiently trained interpreters may still prevent PWCD from accessing available services.

One way in which Majority World countries try to increase services for PWCD is the use of community based rehabilitation (CBR). CBR was initially developed to respond to the lack of disability services in Majority World countries (Kendall et al., 2000), and is defined by International Labour Organization, United

Nations Educational, Scientific and Cultural Organization and WHO (2004:2) as a:

strategy within community development for the rehabilitation,

equalization of opportunities and social integration of all people with disabilities. CBR is implemented through the combined efforts of disabled people themselves, their families and communities, and the appropriate health, education, vocational and social services.

The production and distribution of the manual “Training disabled people in the community” (Helander et al., 1983) allowed for the training of lay persons in rehabilitation, special education, vocational training and other related disciplines (Finkenflügel et al., 2005), which in turn increased the number of CBR workers.

Due to financial and resource deficit, Wirz and Lichtig (1998) identified a significant need for CBR workers in providing appropriate and sustainable support for PWCD and their families. However, a challenge of CBR is to make sure adequate links are made and maintained between health services and PWCD locally. Often this role requires practical and effective delivery of

healthcare in the absence of specifically trained professionals. McConkey et al., (2000) found parents were effective as trainers in disability and developed training manuals for parent groups to use in Africa and elsewhere which could be replicated across Majority World countries.

Despite the prevalence of CBR workers across Majority World countries, CBR fails to meet the needs of PWCD (Wylie et al., 2016). Whatever the specific challenges of each situation, CBR workers, by necessity, need to be trained to deal with a wide spectrum of disabilities. Nganwa et al. (2013) showed that many CBR workers in Majority World countries were not currently trained to provide sufficient intervention for PWCD. More extensive training, however, brings its own financial toll on Majority World country governments.

One of the dangers of judging health service development in Majority World countries by equivalent standards in Minority World countries is the tendency to see Minority World countries’ health services as a gold standard of design, efficacy and achievement. In reality, common health service problems (including low staff numbers, long waiting lists, lack of research, and uneven distribution) are also widespread in Minority World health services. Focusing on services for PWCD: it should be noted that even in Minority World countries (where services for PWCD are typically more developed than in Majority World countries)

services for PWCD experience difficulties. SLT is a relatively new profession in all contexts, and many models of service delivery are used globally (Glykas and Chytas, 2004). In the UK, children from lower socioeconomic groups are more

likely to have poorer language skills compared with children from higher socioeconomic groups (Lee, 2013), and children from some ethnic minorities face greater prevalence of CDs (Strand and Lindsay, 2012). Cochrane et al. (2016) found SLTs working with Indigenous Australians with CDs cited a number of barriers in offering SLT to the population. In many Minority World countries, people who are from low economic statuses or ethnic minorities are both disproportionately affected by CDs and comparatively underserved in terms of support (Hersh et al., 2015).

Both Minority World and Majority World countries experience challenges to their own health systems, including uneven distribution of professional personnel, and disparity of their skill mixes (Frenk et al., 2010). Health services in Majority World countries, however, are more likely to be affected negatively by this, which is further compounded by poor health profiles in terms of disease (Travis et al., 2004). It should be noted, however, that although writers have stated the progress of SLT and other AHPs has occurred at a slower rate in Majority World countries compared to Minority World countries (Thomas, 2013), this

assessment generally does not acknowledge the relative newness of the professions, or the challenges that professions face initially in Minority World countries.

Many health system problems affecting PWCD in Minority World countries are in fact shared with Majority World countries. Even where Minority World

countries have higher numbers of SLTs, rural areas are often significantly underserved, reflecting the situation in many Majority World countries. In these cases, some Minority World countries have developed ways of adapting to these challenges in the use of tele-rehabilitation (Theodoros, 2012). This model of service delivery could also be used in Majority World countries, however the literature shows limited awareness and knowledge of this way of providing such intervention (Mars, 2011) and limited use in Majority World countries.