JCPSLP November 2016

authors are aware of six practising SLPs in Ghana. Half are Ghanaian nationals, all were trained outside of Ghana and all are based in the capital city. There are no free speech- language pathology (SLP) services in the country and the National Health Insurance Scheme does not subsidise speech-language pathology (National Health Insurance Scheme, 2016). Clients frequently report travelling for many hours to attend services. As in many majority-world nations, people with communication difficulties (PWCD) in Ghana require development of a range of rehabilitation services and supports, of which SLP is only one element (Wickenden, 2013). There are a range of people working with PWCD who provide important contributions to rehabilitation. Teachers, teaching assistants, therapists, therapy/ educational aides (known locally as facilitators), community- based rehabilitation (CBR) workers, nurses, carers and parents all provide important work in this arena and are indispensable in providing a network of services and support for PWCD. While every majority-world country and context differs, there are frequently common themes associated with service provision challenges. Often, there is a small workforce, no SLP training programs (Fagan & Jacobs, 2009), little professional development, and limited training for CBR or mid-tier workers in communication disability (World Bank & World Health Organization, 2011). Where SLP services exist, payment is often required and insurance cover for SLP is extremely limited. The community may have limited awareness of communication disability (Wickenden, 2013) and differing beliefs about the causes of communication disability (Ndung’u & Kinyua, 2009). The insider perspective Individuals frequently view a shared experience in differing ways, particularly when their context and cultural backgrounds differ (Nixon et al., 2015). Alternative perspectives can result in tensions within relationships that are frequently unarticulated (Nixon et al. 2015). One aim of this paper is to encourage readers to attempt to view visiting partnerships through the lens of an ‘insider” – someone who may be there before minority-world SLPs arrive, support them during their work, then continues on after they leave – to enable more critical reflection of sustainable relationships. To reflect on issues around partnerships for sustainable service development using an insider perspective, we encourage readers to consider a fictional vignette (Box A). This example offers the chance to reflect on some of the many issues that are present when an “outsider” visits a local service. Navigating relationships between services or clinicians in the majority and minority worlds can be complex, yet undoubtedly globalisation has resulted in dramatically more opportunities for collaboration (Friedman, 2006). With this edition of the journal focused on the theme “Minority-world SLPs in majority-world contexts”, it is important to reflect on what contributes to effective partnerships between majority- and minority-world services. How can minority-world SLPs assist development of sustainable services for PWCD in majority- world countries? In the spirit of a local proverb in Akan “Nyansa nne eti kromu” [translation: Wisdom is not the preserve of one

Box A: Turning the tables: Insiders and outsiders – an example Imagine that you are one of two SLPs and two assistants working in a government clinic in remote Australia. Budget cuts mean equipment is dated or non-existent. You offer services across a huge geographical area to a large population. A skilled and experienced speech-language pathologist from a well-resourced service in Africa offers to volunteer for 3 months. As services are stretched to the limit in your clinic, you are excited to have someone to help you improve services. In the weeks prior to arrival, you exchange emails and Skype calls. You help him/her to organise accommodation. You advise on transport, safety, the weather, the health system, and you collect the volunteer from the airport. Your new colleague is generous in sharing their knowledge. Your service enhances training and expands clinical services. You are working on interesting projects and feel inspired by the rich clinical discussions. But there are challenges. The visiting practitioner struggles to understand how things happen in your context and seems to have an agenda for what is required, which doesn’t match your view of the need. Given the visitor is more experienced, volunteering their time, and contributing resources, it is hard to argue. At a service level, there are small issues. The visiting practitioner has trouble with the language, so cannot work independently. Clients often don’t understand what he/she means when explaining things, but are too polite to mention it. There are awkward moments – such as when the visiting practitioner tells clients to focus on giving instructions to their children rather than engaging in reciprocal play, or hints that the type of therapy you are offering may not be best practice. The visiting practitioner doesn’t know how to do the things that are considered important in your context (e.g., making sure certain families have transport money or helping to find a school that will take their child). You understand that it is simply a difference to how things are done in Africa. The visiting practitioner helps to train the assistants in a particular type of therapy. Everyone is excited about skill development. It is wonderful to make the connection, but all the things you need to organise for the visitor are added on top of your usual workload. The visiting practitioner returns to Africa and you are back juggling the demands of service provision to desperate clients, and the many other needs (e.g., awareness raising, training others, special projects to improve services, prevention work, and trying to build a profession). The visiting practitioner stays in touch for some months and sends some invaluable resources. The assistants need further support in adapting their new programs to the culture, and you struggle to support them and maintain your other work. After two months, another NGO from Africa offers to assist in the development of autism services and would like your involvement. You feel like you are still playing catch-up with your usual work. What is your response?

Josephine Ohenewa

Bampoe (top), and Nana Akua Owusu

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JCPSLP Volume 18, Number 3 2016

www.speechpathologyaustralia.org.au