Global theme 4 Embedding services in context

The fourth and final outsider global theme described the overall context of Uganda as outsiders saw it. It comprised two organising themes, which explored the varied challenges to the profession, the need for groups or

organisations rather than individuals to prioritise SLT, and the need for services to improve for all Ugandan PWCD.

Organising theme 1. Contextual factors

Contextual factors considers the setting of Uganda as a country and some of the challenges of working within it. Contextual factors groups together four basic themes.

Table 4.16 Outsider global theme 4. Embedding services in context

BT1. Uganda is a Majority World country

This first basic theme described the context of Uganda as a Majority World country in terms of its development status. Outsiders acknowledged the context of working in Uganda as being different from working in a Minority World

context. This context acted as a backdrop to explain the challenges filtering down from the general infrastructure, health infrastructure and within SLT. The majority of outsiders explored the need for Ugandan PWCD to be included in society and have increased rights. One outsider went further and linked the need for PWCD to have improvements to employment opportunities so as to help bolster Uganda’s economy.

OU14: “Uganda is gonna have this problem of very uh disparate and diverse communities all over the place, very poor emotionally, poor infrastructure to get between them, you know, um even basic health is gonna be a challenge”

BT2. Bureaucracy, fraud and corruption

This second basic theme described the perception of the levels of bureaucracy, fraud and corruption in Uganda. Outsiders described how these challenges appeared in many government and national settings, and within NGOs. Despite these challenges, outsiders felt they were able to achieve some successes:

OU11: “it’s quite an achievement to be able to [establish an SLT course] within their highly bureaucratic, regimented university system”

Basic themes Organising themes Global themes

1. Uganda is a Majority World country 1. Contextual factors 4. Embedding services in context 2. Bureaucracy, fraud and corruption

3. Prioritisation

4. Health infrastructure

1. Severity of conditions 2. Service challenges 2. Access inequality

3. Awareness of CD 4. Profession needs

BT3. Prioritisation

One challenge often discussed by outsiders was the cultural difference in attitude to training and meetings, and receiving expenses for attending them. Although outsiders did not always agree with this practice, it was generally accepted and respected. However outsiders noted that on occasion they thought that the compensation asked was inappropriate.

As well as outsiders considering the overall priorities of the health service, outsiders also stated that even for PWCD and their families, that SLT is likely to be a lower priority than other health care. Although outsiders understood this, they noted that PWCD would continue to face challenges until they were supported by services.

OU14: “most of the emphasis is on stopping the malaria…. obviously you can use that in lots of different contexts… But of course it does mean that you’re always gonna have a very marginalised proportion of the population who’ve had malaria and have got these deficits”

BT4. Health Infrastructure

Outsiders viewed the challenges of Uganda’s health infrastructure as a whole. A lack of allied health professionals, SLTs, and services for PWCD contributed to weaknesses. As such, many viewed SLT in Uganda to be built on weak

foundations. They discussed how it would have been beneficial for the sustainable development of SLT if the infrastructure was more developed, however, they balanced this against a need to start somewhere. There was a tension of beginning a service where infrastructure and other services were lacking, which begged the question of is there a right way to start services?

OU14: “we all know, don’t we, that Uganda’s history over those 50 years: it’s been a huge struggle. So, you know, trying to set up a health service in this kind of situation is like, you know, mindblowing

Organising theme 2. Service challenges

The second organising theme in this global theme described challenges to services for PWCD. Services for PWCD needed to improve for all Ugandan PWCDs. The theme described a need for increased geographical presence for services (to increase access) and a need for increased awareness of CDs and services that can support PWCD. The theme also described the specific needs of the SLT profession.

BT1. Severity of conditions

This theme described how services for PWCD and SLT needed to provide for all PWCD, from people with mild to severe difficulties. Outsiders often described how the CDs in Uganda were often severe or moderate. Outsiders felt that a service needed to be able to work for all the PWCDs, regardless of the severity.

OU14: “Because [Ugandan SLTs] have got a massive great soup of people…what proportion of these people have got severe problems? Moderate problems?”

BT2. Access inequality

This theme explores how there was inequality amongst PWCD in accessing services. Factors affecting access included: location, as there were fewer SLTs working in rural settings (though SLT numbers were also low in urban areas); direct costs of treatment; and indirect costs of treatment (such as travel, loss of earnings). Some outsiders aimed to improve accessibility for Ugandans by working for free or re-investing money from private practice into the SLT service.

OU8: “Uh, I suppose it’s effectively like private patients but I don’t … I never charge anybody… if it’s um NGO crowd that can afford to pay they’re willing to make a donation to our organisation”

BT3. Awareness of CD

This theme described the lack of awareness of both CDs, and services for PWCD in Uganda. Although awareness of CDs in some areas may have

improved, as a whole, awareness amongst the general population and potential referrers or sign-posters was at a low level.

OU9: “ there was still stories of like a little boy he had been locked up by his parents because he had cerebral palsy and they didn't understand what that meant or in their culture”

BT4. Profession needs

Outsiders felt that the profession of SLT had a clear need for continued development. This included the recognition of SLT as a profession and appropriate policy, as well as the provision of employment opportunities for SLTs. Outsiders felt that one way to strengthen and safeguard the profession was to obtain recognition of the profession. Outsiders had worked to try and achieve the recognition of the profession within relevant regulatory settings, and to create government employment positions. However, a lack of recognition meant that there were a number of difficulties in practicing as an SLT in

Uganda. For example: whilst some Ugandan SLT graduates were able to work as an SLT, a number of them returned to previous jobs and tried to incorporate SLT into these jobs or additional private work, or even move abroad to work as an SLT. Supportive measures were crucial for the sustainability of the

profession.

OU1: “all those who were clinical officers went back to their clinical officers post… and tried to do whatever speech therapy they could there but they were still employed as clinical officers they weren’t recognised as speech and language therapists”

4.4.3.5 Summary

These four global themes describe how outsiders perceived their contributions to services for PWCD. In summary, four main findings were produced. Firstly, outsiders discussed the colonial history of Uganda. They were aware of their privileged status in Uganda and typically uncomfortable with it. They were aware that outsider-status carried certain privileges and opportunities: being able to navigate the political structures with relative ease, and able to suggest therapy techniques that were seen as unconventional in Uganda. Outsiders

described how they were not the most appropriate people to work with PWCD in Uganda, and that insiders were. Although outsiders viewed Ugandan SLTs as ultimately more appropriate for working with PWCD in Uganda, outsiders were concerned that insiders were unready to work in lead roles such as lecturing. Roles between insiders and outsiders were divided; outsiders viewed outsider roles as providing clinical expertise, and insider roles as providing cultural expertise.

Secondly, though outsiders viewed themselves as having relationships with both insiders and outsiders, there were different focuses in these relationships. Outsiders saw their relationships with other outsiders as based in friendship and personal support. Whilst some outsiders did mention receiving personal support and friendship from insiders, their relationships with insiders were generally discussed in terms of providing strategic support to the development of services for PWCD.

Thirdly, outsiders felt the model of development approach used was directly related to the quality and sustainability of their contribution. Outsiders were keen to describe the need for a custom approach for Uganda, rather than the replication of approaches used in the UK, and often critiqued other outsiders for not altering their approaches to therapy to reflect the different context.

Finally, outsiders viewed the ability to make a practical difference as important. Though a minority of outsiders felt a difference could be made through indirect outsider roles such as fundraising, the majority of the outsiders interviewed viewed “making a difference” as contributing in a direct role such as training, lecturing, or clinical work. The same majority of outsiders felt that outsiders who wanted to observe or only be involved for a very short time (e.g., for a few days as they passed through the country) had a negative effect, with many outsiders describing how they actively discouraged such attempts from other outsiders. Such offers of support were seen by outsiders as disruptive, as well as