3.4. Experts recommend that hearing aids should be provided within the context of a broader Ear and Hearing Care programme, but multiple implementation challenges exist.
Hearing aids are only one component of a comprehensive service delivery and rehabilitation model, known as Ear and Hearing Care (E.H.C.), which is required to effectively identify and address pathologies of the ear. The W.H.O. promotes E.H.C. programmes and strategies. Services are required across all levels of a health system, from the community to the hospital level. Each health level would involve activities from prevention and raising awareness to screening and detection to treatment and rehabilitation (refer to Appendix B. for detailed activities to be provided at each level of the health system).
Beyond general health system constraints, multiple challenges associated with the implementation of E.H.C. in L.M.I.C.s exist, including:
- LACK OF A NATIONAL OR SUB-NATIONAL E.H.C. STRATEGY. A W.H.O. multi-country assessment published in 2013 reported that of the 46 L.M.I.C.s that participated, 41% did not have a national or subnational strategy for E.H.C..30
- LACK OF PLANNING AND BUDGETING FOR SERVICES, including required equipment, human resources and products. In the same W.H.O. assessment, countries cited lack of financial resources and lack of human resources as the primary reason for not having developed a national program. Competing health priorities and insufficient political will were also noted.31
- LACK OF TRAINED HEALTH WORKERS, including audiologists and E.N.T. surgeons at all levels. Many countries require that hearing loss diagnosis and hearing aid fitting only be conducted by audiologists or E.N.T. surgeons. L.M.I.C.s generally have a shortage of audiologists—who typically need two years of post-graduate coursework—which limits the ability to scale services. Only six out of 37 low and lower-middle-income countries had more than one audiologist per 1 million people compared to 17 out of 20 upper-middle- and high-income countries.32 The low availability of audiologists can partly be attributed to the migration of many audiologists to higher income countries. For example, approximately 50% of Indian audiologists are estimated to have relocated to other nations.33
- LACK OF TRAINING TO SUPPORT TASK SHIFTING. While training models are available for E.H.C. from the W.H.O., there are no training modules available specifically for hearing aid provision; therefore, N.G.O.s have trained community health workers, nurses and audiology technicians by creating their own training modules to provide hearing care services.
As most countries in East and Central Africa lack financial resources to develop national E.H.C. strategies, Starkey Hearing Foundation, the German Federal Ministry of Economic Cooperation and Development (B.M.Z.) and C.B.M. have funded the East and Central Africa E.H.C. Forum, an advocacy group created by independent audiologists and E.N.T. surgeons in 2016. The forum is advocating that all countries in the region develop national plans for E.H.C. by end of 2019. These partners and the forum have advocated for and/or have supported the development of national plans for E.H.C. in the following countries: Burundi, Democratic Republic of Congo, Ethiopia, Kenya, Madagascar, Malawi, Nigeria, Rwanda, Tanzania, Uganda, Zimbabwe, and Zambia.
