Partnerships between Uganda, Kenya, and Rwanda and the United Kingdom to address Sustainable Development Goal 17 for people with communication disability

Abstract

Purpose

Minority World countries have often been involved in supporting services for people with communication disability (PWCD) in Majority World countries. In East Africa, this support has historically involved speech-language pathologists (SLPs) from Minority World countries providing therapy; later evolving to include partnerships between Majority and Minority World organisations providing education, training, and support—sometimes with the aim of increasing service sustainability. Our objective is to provide an overview of how partnerships for the goals (SDG 17) has been realised for speech-language pathology services in three East African countries (Uganda, Kenya, and Rwanda). For SLPs, we consider training and education, research opportunities, and the development of the profession. For PWCD, we consider the equity of services.

Result

We identify key challenges and successes of UK/East African partnerships, identifying steps for improvement for robust speech-language pathology partnerships.

Conclusion

We suggest three key approaches for better-designed partnerships: (1) Improve accessibility, by expanding services to rural areas and coordinating fee setting. (2) Ensure local stakeholders and professionals are included in meaningful and agreed ways. (3) Ensure partnerships complement existing services and are culturally appropriate. These approaches support related goals to achieve better services for PWCD. This commentary paper focuses on good health and well-being (SDG 3); quality education (SDG 4); decent work and economic growth (SDG 8); industry, innovation, and infrastructure (SDG 9); reduced inequalities (SDG 10); partnerships for the goals (SDG 17).

Keywords:

• Sustainable Development Goals (SDGs)
• good health and well-being (SDG 3)
• quality education (SDG 4)
• decent work and economic growth (SDG 8)
• industry, innovation and infrastructure (SDG 9)
• reduced inequalities (SDG 10)
• partnerships for the goals (SDG 17)
• communication disability
• swallowing disability
• East Africa
• UK
• partnerships
• service development

Introduction

The United Nations’ Sustainable Development Goals (SDGs)—169 targets across 17 areas of development—were created to improve lives, services, and infrastructure worldwide (United Nations, 2015). Services for people with communication disability (PWCD) are generally less resourced in Majority World countries, often supported through partnerships with Minority-World-based individuals or organisations. Such partnerships have characterised the development of many East African speech-language pathology services and have included different approaches: long-/short-term, individual-/organizational-led, internally-/externally-initiated, clinic-based, or education-/training-based. This commentary will explore how partnerships for the goals (SDG 17) has been realised through speech-language pathology partnerships in three East African countries (Uganda, Kenya, and Rwanda), exploring speech-language pathology services (considering the education and training of SLPs, and the development of the profession and research opportunities: intersecting with quality education (SDG 4), decent work and economic growth (SDG 8), industry, innovation and infrastructure (SDG 9) reduced inequalities (SDG 10) and the context for PWCD (considering service availability and accessibility: intersecting with good health and well-being (SDG 3), quality education (SDG 4), reduced inequalities (SDG 10), and encompassing a critical discussion of partnerships in terms of suitability for achieving the goals.

Uganda, Kenya, and Rwanda are East Africa countries with a combined population of 119 million. Before their independence, Uganda and Kenya were colonised by Britain, Rwanda by Belgium. Colonial legacies have resulted in diminished human development scores as indicated by the United Nations (2022): Kenya has a “medium” ranking, whilst Uganda and Rwanda have a “low” ranking. This paper was written by three SLPs in partnership. We met four times over Zoom to reflect on our thoughts and experiences of speech-language pathology services in Uganda, Kenya, and Rwanda and the role of partnerships. We identified relevant SDGs for discussion and created a dedicated WhatsApp group for work-sharing.

Partnerships for the goals (SDG 17): A history of speech-language pathology partnerships between the UK and Uganda, Kenya, and Rwanda

Uganda

The first documented Ugandan speech-language pathology service was provided in 1986 by Kyambogo University and UK-based non-government organisation (NGO) Volunteer Services Overseas (VSO), using British SLPs to provide intervention for PWCD in Kampala (Barrett & Marshall, 2013). Under this service, up to 98% of Ugandans with disabilities were geographically isolated from potential inclusion (Hartley & Wirz, 2002). In the early 2000s, a stakeholder workshop (with representatives including PWCD; four Ugandan government ministries; major NGOs for people with disabilities; and health, education and community workers) was convened to explore more-sustainable models of service delivery, resulting in a Ugandan speech-language pathology undergraduate program at Makerere University with VSO SLPs and Ugandan stakeholders collaborating to deliver training, and a Ugandan government pledge to employ graduates (Robinson, Afako, Wickenden, & Hartley, 2003).

A mentoring project, led by a UK SLP, offered continuing professional development (CPD) to Ugandan graduates (Marshall & Wickenden, 2018). UK-based NGO Multi-Agency International and Support (MAITS) partnered with Mulago Hospital to train nurses and Parent Trainers to support parents of children with swallowing disabilities (de Silva & Hamden, 2016). The Uganda Speech and Language Therapist Association aims “to ensure delivery of high quality [speech-language pathology] services through innovative partnership with training institutions, governments, and communities in Uganda and beyond” (Uganda Speech & Language Therapist Association, 2015, p. 4). It reports ∼68 member SLPs in Uganda (personal communication, P. Nakato, 01/04/2022).

Kenya

Kenyan organisations partnered with VSO from the late 1960s to receive SLPs (Staley, 2009). The majority of SLPs have worked in Nairobi, mainly through private institutions (Jochmann, 2006). Some services, including those offered by Yellow House, an NGO founded by an Australian SLP and currently run by a UK-based SLP, are provided outside of the capital (Staley, Hickey, Rochus, et al., 2021) and provide speech-pathology intervention for both adults and children. Moi University and Kenyatta University both developed Masters-level speech-language pathology programs in the last decade through international partnership (Staley, 2013). SLPs, student SLPs, assistant SLPs, and affiliated overseas SLPs are supported by the Association of Speech and Language Therapists Kenya (ASLTK). There are ∼40 members of ASLTK, including East African and foreign SLPs (Association of Speech & Language Therapists Kenya, 2022a). ASLTK are calling for a new Kenyan speech-language pathology training program, adapted from the Makerere University curriculum (Alighieri et al., 2022). International partnerships have delivered CPD since the mid-1990s, continuing as recently as 2018 (Association of Speech & Language Therapists Kenya, 2022b; Marshall, 1997).

Rwanda

Compared with Uganda or Kenya, speech-language pathology is a relatively recent profession in Rwanda. Speech-language pathology services began to increase in Kigali in the 2010s and in 2012, the first Rwandan SLP was appointed to King Faisal Hospital, one of Rwanda’s National Referral Hospitals, after graduating from Uganda’s Makerere University (Bowen, 2022). In 2013 international volunteers began a clinic offering speech-language pathology in partnership with Rwanda Military Hospital and VSO, serving adults and children PWCD (International Communication Project, 2013). Subsequent international and local SLPs have worked with PWCD in hospitals, schools, and NGOs (International Communication Project, 2013). More recently, the United Nations High Commissioner for Refugees collaborated with Manchester Metropolitan University to enhance services for refugees with communication disabilities in Rwanda (Marshall & Barrett, 2018). A speech-language pathology training course is in development at the University of Rwanda, seeking potential funding partners (Mukara et al., 2017). MAITS has worked with local organisations, providing training to clinical- and social-workers in supporting children with feeding disabilities (Palha De Sousa et al., 2019) and empowering Parent Experts in supporting other parents and children (Beck et al., 2018). There are ∼8 SLPs in Rwanda, with six in practice (personal communication, A. Wekhoola, 10/04/2022). The Rwanda Speech and Language Therapy Association is in development, set to include both SLPs and audiologists (Rwanda Speech & Language Therapy Association, 2022).

Have speech-language pathology partnerships improved the context for PWCD?

Trends towards longer-term, more-sustainable international partnerships have led to an increase in East African speech-language pathology services and the number of PWCD able to access support across formal and informal settings. Long-term partners, including Yellow House, provide speech-language pathology services for PWCD in clinical and educational settings (Staley, Hickey, Rule, et al., 2021), supporting good health and well-being (SDG 3) and quality education (SDG 4). Partnerships have also educated and empowered carers of children with communication disabilities through Communication Camps (Turatsinze, 2015) and parent training. New roles, including Parent Expert and Parent Liaison Officer enrich local services whilst while providing a livelihood for local carers of PWCD (Beck et al., 2018). Despite good health and well-being (SDG 3) focussing on healthy lives and well-being for all, access to speech-language pathology remains restricted in rural areas (Wylie et al., 2016), or prohibitive due to fees or indirect costs (Barrett, 2010). The emerging partnership trends of expanding beyond capital cities [e.g., in the case of Yellow House being based in Western Kenya, servicing a region away from Nairobi (Staley, Hickey, Rochus, et al., 2021)] and co-ordinated fee-setting may help to achieve reduced inequalities (SDG 10).

Have speech-language pathology partnerships supported the speech-language pathology profession?

Partnerships in East Africa have worked towards quality education (SDG 4) in two main ways: creation of speech-language pathology education opportunities, and provision of speech-language pathology services for East African children and young people. Despite increasing the number of trained SLPs in the region, speech-language pathology programs have faced challenges. The Ugandan partnership between VSO and Makerere ended abruptly in 2011 (Sowden, 2018). Makerere University now runs the course with a local speech-language pathology coordinator. The program at Moi University also ended early, possibly due to unbalanced involvement from the partners, causing disruption to students and reducing the number of SLPs in East Africa (personal communication, D. Musasizi, 12/04/2022). Education and training have continued through other partnerships: East African SLPs have accessed in-person CPD through mentoring (Marshall & Wickenden, 2018) and through post-graduate scholarships overseas (The University of Sheffield, 2014).

Locally qualified SLPs in Uganda, Kenya, and Rwanda have been employed in hospitals, rehabilitation centres, clinics, schools, NGOs, child development centres, and nursing homes. Some are in private practice. Some are directly employed by the state, health and education services, or NGOs. Others have struggled with employment due to in-country and international pressures. The Ugandan Ministry of Health’s plan to employ graduating SLPs has not been realised, challenging the systematic development of the profession and decent work and economic growth (SDG 8). Many of the original cohorts of Ugandan-trained SLPs practice the profession in hospitals under their former, non-speech-language pathology job titles (Sowden, 2018). Government and university policies, including the requirement of postgraduate degrees for progression to specialist SLP and lecturing roles, and age restrictions faced by lecturers and university teaching assistants (Barrett, 2010), may create barriers to individual SLPs and service development. Similarly, the Kenyan government does not recognise the speech-language pathology profession, creating challenges in public employment (Staley et al., 2019).

Partnerships may also threaten the employment or livelihood of local SLPs. Foreign-sponsored speech-language pathology can undermine local SLPs or institutions either because local PWCD exhibit a preference for foreign services, or because discounted services undercut local SLPs who rely on a fair price for their work (Sowden, 2018; Staley, Hickey, Rule, et al., 2021). Hosting and inducting visitors from the Minority World also takes time and may come at the expense of paid work for local SLPs (Marshall, Owusu, & Sowden, in press).

The trend from individual-based, unsustainable working towards organisation-based, sustainable partnerships has helped progress industry, innovation, and infrastructure (SDG 9) particularly in the development of training. The development of The Association of Speech and Language Therapists Kenya (ASLTK) by Kenyan and British SLPs, has better-enabled peer-supervision and CPD.

The historical dominance of foreigners in research is being challenged by an increasing amount of literature authored and co-authored by East African SLPs. Many East African SLPs report positive collaborations with Minority World researchers. However, we have learned that many other East African SLPs characterise research collaborations as unbalanced in favour of Minority World researchers. SLPs in East Africa have reported to us that their ideas and research have been used in grant applications without acknowledgement; that they have not received copies of published articles from their co-authors, which may be inaccessible behind paywalls; who feel their names are included as co-authors only to legitimise foreigners’ research (personal communication, D. Musasizi, 29/01/2022). As the speech-language pathology profession faces calls to decolonise practice (Watermeyer & Neille, 2022), it is necessary for collaborative research to be created meaningfully.

Successful partnerships support clinical innovation by developing research and resources in collaboration. For example, an East African collaborated with Royal Kentalis to develop a Kiswahili screening tool (Kabenge et al., 2020), and East African SLPs developed speech sound resources for Kiswahili speakers in partnership with The Leaders Project (Musasizi et al., 2022). Online platforms allow for resource-sharing and networking. The Global SLTs WhatsApp Group was launched in 2015 by five Ugandan SLPs and one British SLP (including the first and third author of this commentary) to share clinical skills and employment and funding opportunities (Sowden & Musasizi, 2017). The group has 65 members in East Africa, South Africa, the UK, and the USA. Funding has been provided by UK NGOs, including Smile Train, to enable East African SLPs to attend and present at international conferences (Musasizi et al., 2022) which are often hosted in Minority World countries. Financial support can also take the form of fee reduction, which works towards reduced inequalities (SDG 10). For example, the UK professional regulation body The Royal College of Speech and Language Therapists waived membership fees for some SLPs in Majority World countries (personal communication, K. Willis, 22/10/2019), benefitting ∼9 East African SLPs.

Strengthening partnerships for the goals

Partnerships between Majority and Minority World countries have advanced Sustainable Development Goals through speech-language pathology services in Uganda, Rwanda, and Kenya. A key success of partnerships in working towards good health and well-being (SDG 3), quality education (SDG 4), decent work and economic growth (SDG 8), industry, innovation, and infrastructure (SDG 9), and reduced inequalities (SDG 10), has been an increase in the number of trained East African SLPs, assistants and Parent Experts, facilitating wider-reaching and more culturally-appropriate services for PWCDs. However, partnerships still face challenges in terms of development, extent of collaboration, and potential for sustainability (Sowden, 2018). Here we summarise key challenges faced by partnerships and offer suggestions to mitigate them.

• Services for PWCD may be inaccessible for many. Expansion of services to rural areas and coordinated fee setting, without undercutting local SLPs, will improve accessibility.

• Partnerships may not include local stakeholders in a meaningful way. Local SLPs and PWCD should be centred in partnerships and lead when developing services, training programs and research projects. Goals, roles and responsibilities should be agreed and clear for all involved (Sowden, 2018).

• Partnerships may not be designed with context in mind. Partnerships need to compliment, not compete with, existing services. New services should be culturally appropriate and work within available resources.

Summary and conclusion

Services for PWCD in East African countries, including Uganda, Kenya, and Rwanda, have often developed through partnerships with Minority World countries, including the UK. We have outlined how partnerships for the goals (SDG 17) have worked towards supporting good health and well-being (SDG 3), quality education (SDG 4), decent work and economic growth (SDG 8), industry, innovation and infrastructure (SDG 9) and reduced inequalities (SDG 10). We have identified key successes and challenges of partnership-based working, offering suggestions to optimise partnerships for continued support for PWCD, SLPs, and the SDGs.

Acknowledgements

We thank Peniniah Nakato, Cate-Maud Asiimwe, and Isaac Ojok for their support and suggestions for our paper. We thank all East African SLTs who have trusted us with sensitive information.

Declaration of interest

No potential conflict of interest was reported by the author(s).