A Story of Sustainable Service Development in Malawi

One of the many challenging aspects of coming home to australia is where to begin with describing your experience.... How can you possibly capture the thousands of moments across 18months all in response to "how was your trip?".... it can be so hard to summarise, especially explaining what i actually did at work!!

So for those of you interested in more details of my project in Malawi, you might catch a glimpse by reading this document which i have recently written for a presentation proposal to the annual Speech Pathology Australia conference - Aspire 2009. While it is a bit formal and may be full of speechie jargon, it may be of interest!


A Story of Sustainable Service Development in Malawi

Abstract

As a Speech Pathologist with 5 years experience across a variety of clinical sectors, I aspired to expand my horizons and accepted a position in Malawi, Africa. This undertaking greatly challenged my worldview of our profession. I worked for Australian Volunteers International (AVI) for an 18month contract in a community rehabilitation program in Malawi. The role required the development of Malawi’s first Speech Pathology service. This unique position provided first hand experience of health care delivery in resource poor settings and developing countries.

This presentation will address the global health issues encountered in developing countries in particular those faced by the disabled population in Africa. The Malawi project will be the context through which I address processes, innovations and global challenges. Issues of service development, sustainability and advocacy will be highlighted.

The reflections and outcomes shared will inform and challenge Speech Pathologists to increase their understanding of global issues facing our profession.

Introduction

Individuals within many developing countries struggle with access to food, clean water, shelter and security from conflict. These and many other issues contribute to the high death and disability rates, with ongoing struggle for access to the most basic health care services. Most developing countries are challenged by an acute shortage of skilled professionals to staff the health services.

Located in sub-Saharan Africa, Malawi is one of the world’s most densely populated and least developed countries with a population of 13.9million. There are no qualified or practicing Speech Pathologists. Malawi has a relatively young population with 50% under the age of 15years and a total life expectancy of 39 years. Over 65% of the population are living in poverty, on less the 50c per day. (WHO, 2004) Malawi, as with many other African nations has health indicators amongst the worst in the world.

Even without a disability, living conditions are extremely difficult in so many developing countries, while children with disabilities are often neglected, stigmatised or even left to die. The rates of disability are very high due to limited access to the most basic health care and education resulting in high numbers of mortality and disability from preventable illness. Poverty is commonly described as more than simply a lack of money, but more specifically a lack of opportunity.

This presentation will outline the clinical aspects of the service developed in Malawi and aims to inform, and hopefully inspire the audience to consider global issues facing our profession.


The Malawi Project

Aim
To develop a sustainable speech pathology service in Malawi for the assessment and management of children and adults presenting with speech, swallowing, hearing, and learning disabilities. This was achieved by raising the capacity of local rehabilitation staff in the Lilongwe and Blantyre Medical centres in Malawi.

The setting
SOS children’s village is a non-government not for profit organisation that provides services for orphaned and abandoned children and their communities. Each village includes an orphanage, a variety of schools, social and community services, medical centre and children’s rehabilitation program providing a variety of services for children with disabilities. Over 1,000 children are referred each year. After a basic assessment conducted by a member of the multidisciplinary team the children attend weekly groups targeting various therapy goals. Historically physical rehabilitation, activities of daily living and education have been the primary focus. Over the past years the staff have identified a growing need for communication services and without access in Malawi, they advertised for international assistance.

The Program (Results):

Observation Phase
The initial months of the project were spent observing the existing rehabilitation program and collecting data on clients requiring speech pathology assessment and intervention. Prior to arrival the staff had compiled a list of 30 children from the current caseload attending the children’s rehabilitation program - an average of 500 children per week. In the initial 2 months of screening, 200 were identified for the program with a vast mix of clinical presentations. Basic information was captured in a database and then analysed to identify common disabilities and patterns emerging for therapy goals. It was at this time that 2 primary clinicians were identified for the ongoing management of the program and training commenced.

Development Phase
Group therapy was the only alternative given the magnitude of children requiring assistance and the high number of new referrals each day. The Groups included:
Socialisation
Speech Sounds (Articulation & Phonology)
Early Language
AAC
Hearing Impaired
Oral Motor and
Eating & Drinking

The program continued to grow with the caseload rising to over 300 as further screening and assessment was conducted. News of the services spread fast and further changes were made, services for adults were developed, a hearing-screening clinic was established and home visit programs commenced.

Education & Training
· The 18 months were spent intensively training, mentoring, supervising and encouraging the 2 primary clinicians who would continue the management of the program along with the other program staff.
· Ongoing education was provided via in-services within the multidsicplinary team, lectures at the nursing and rehabilitation assistant colleges, workshops for families, villages, community and traditional leaders. Additionally low cost, culturally appropriate training methods were developed with accompanying resources.
· The education needs of the staff will be ongoing, while I am continuing my support from Australia, ideally these staff and many in the future require a long term solution to the development of the profession.

Resource Development
· Culturally appropriate screening & assessment tools were modified, developed and translated. Each group has a resource kit available including session outlines, recommended games and activities, and reading materials for ongoing professional development. Home visit and rural outreach clinic assessment kits were also created for both communication and swallowing assessments.
· From pens to therapy resources everything needed to be sourced, fundraised for, or hand-made using creative and cost effective methods.

Barriers and challenges to sustainability
· Limited access to education, opportunities and sustainable economic and health resources
· Extreme poverty and high burden of disability and disease
· Cultural & social perspectives of disability and health care seeking behaviours
· Language, literacy and traditional beliefs.

Future Directions & Considerations:
The development of any new service is often complicated and not without its own unique challenges. When considering the global impact of our profession, it is imperative to address the needs of the community and the resources available to them.

How then do we use our common knowledge, beliefs and scope of practice in countries where 60% of children are malnourished? Do they really need speech therapy or do they need food, safe water and medicine to prevent the disabilities in the first place? What are the priorities?

At a time when our governments are setting international targets in millennium development goals to reduce poverty, mortality rates and increase education, what is our role when we have the knowledge and skills, and there are people in great need of it? This project left many questions unanswered regarding sustainability and development priorities, however it did confirm the need for:
· Sharing skills and resources
· Advocating and networking
· Providing education and awareness
· Considering our role in community participation and prevention.

Aspirations change people, Is it possible they could change our profession?