African Journal of Disability 
ISSN: (Online) 2226-7220, (Print) 2223-9170
Page 1 of 9 Original Research
Communication rehabilitation in sub-Saharan Africa: 
The role of speech and language therapists
Authors: Background: Workforce factors present a significant barrier to the development of rehabilitation 
Karen Wylie1,2,3 
2 services for people with communication disabilities in sub-Saharan Africa (SSA). Exploring Lindy McAllister  
Bronwyn Davidson4 how the work of speech and language therapists (SLTs) in the region is organised and delivered 
Julie Marshall5 can provide insight into existing services, areas for future workforce development and 
improved rehabilitation access for people with communication disability.
Affiliations:
1ENT Department, Korle Bu Objectives: This paper describes the employment and service provision patterns and work 
Teaching Hospital, Ghana roles of a sample of SLTs in SSA.
2Work Integrated Learning Method: A broad, purpose-designed, mixed-methods survey was designed to collect data 
Department, Faculty of from SLTs living in Anglophone countries of SSA. Descriptive statistics and qualitative content 
Health Sciences, University 
of Sydney, Australia analysis were undertaken. This paper reports on a subset of data from the wider survey.
Results: A description of the employment and work roles of the 33 respondents to the survey 
3Department of Audiology, and characteristics of their service users is presented. SLTs were commonly employed within 
Speech & Language Therapy, 
University of Ghana, Ghana private and not-for-profit sectors and frequently worked in temporary jobs. SLTs engaged in a 
range of work roles, including capacity building and training others. Services were provided 
4Department of Audiology & by SLTs across age ranges, health conditions and settings, with paediatric, urban services 
Speech Pathology, The commonly reported. Costs for service users and urban-centred services give indications of 
University of Melbourne, barriers to service access.
Australia
Conclusion: Knowledge of the way in which speech and language therapy services are 
5Health Professions organised and provided has the potential to shape the development of communication 
Department, Manchester 
Metropolitan University, disability rehabilitation in SSA. This research has identified a range of issues requiring 
United Kingdom consideration as the profession develops and grows.
Corresponding author:
Karen Wylie,  
kwyl1124@uni.sydney.edu.au Introduction
Despite an increasing global focus on inclusion and the rights of people with disabilities (PWD), 
Dates:
Received: 06 Nov. 2016 rehabilitation services continue to be extremely limited in countries of the Majority World, 
Accepted: 25 July 2017 including in sub-Saharan Africa (SSA). Many PWD report limited access to rehabilitation services 
Published: 12 Apr. 2018 (Eide & Loeb 2006; Eide & Kamaleri 2009; Loeb & Eide 2004; World Bank & World Health 
How to cite this article: Organization 2011). Increasing the availability of rehabilitation and habilitation services for PWD 
Wylie, K., McAllister, L., is critical and forms one of the three objectives of the World Health Organization’s Disability 
Davidson, B. & Marshall, J., Action Plan 2014–2021 (2015). (Note: In this paper the terms Majority and Minority World are 
2018, ‘Communication used to replace the terminology ‘developed’ and ‘developing’ countries.) This paper focuses on 
rehabilitation in sub-Saharan 
Africa: The role of speech and workforce factors limiting the development of rehabilitation services for people with 
language therapists’, African communication disability (PWCD) in SSA. PWCD have been described as:
Journal of Disability 7(0), a population whose ability to communicate is affected by their response to an impairment and/or social 
a338. https://doi.
org/10.4102/ajod.v7i0.338 and contextual factors which interrelate with each other and with the person themselves, resulting in 
impaired communication skills. (Hartley 1998:277)
Copyright:
© 2018. The Authors. Two alternate paradigms have commonly been used to conceptualise disability. Historically, the 
Licensee: AOSIS. This work 
is licensed under the medical model of disability was the dominant approach and considered impairment to be the 
Creative Commons causative factor in disability, while more recently the social model of disability attributed societal 
Attribution License. and environmental factors as the sole cause of disability. While debates about disability theory 
continue (Shakespeare & Watson 2002), in practice the biopsychosocial model of disability 
Read online: (World Health Organization 2001) has become widely adopted in rehabilitation. This model is 
Scan this QR represented in the International Classification of Functioning Disability and Health (World 
code with your 
smart phone or Health Organization 2001) and represents disability as a result of the inter-relationship between 
mobile device a health condition, personal and contextual factors, subsequently impacting a person’s activities 
to read online.
and participation.
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Page 2 of 9 Original Research
Responding effectively to the diverse rehabilitation needs of education and community engagement (World Health 
PWCD requires a workforce with a suitable mix of skills; Organization 2015).
however, there are recognised global shortages in the 
rehabilitation workforce, particularly in the Majority World In the Majority World, including SSA, CBR services and 
(World Health Organization 2017). In SSA, speech and medical rehabilitation services frequently coexist (World 
language therapists (SLTs) are rarely available (Fagan & Health Organization 2015). Medical rehabilitation is often 
Jacobs 2009) and community-based rehabilitation (CBR) associated with health care systems, with services provided 
workers frequently lack training in communication disability by professionals with skills in a particular area of rehabilitation 
(Nganwa, Batesaki & Mallya 2013; World Bank & World (Haig 2013), including rehabilitation physicians, occupational 
Health Organization 2011). Indicative figures for the therapists, physiotherapists and SLTs. In countries of the 
availability of SLTs in SSA are broadly suggestive of a Minority World, medical rehabilitation services are frequently 
workforce density of between 0 and 6 SLT per million well developed. In contrast, CBR is widely adopted in 
population (Fagan & Jacobs 2009; Wylie et al. 2012). (Figures Majority World including SSA (Hartley et al. 2010) and offers 
exclude South Africa where the profession of SLT is well a broad approach to rehabilitation, using five interrelated 
established [Pillay & Kathard 2015].) However, there are components: health, education, livelihood, social and 
indications of growth in the SLT profession in SSA across empowerment (International Labour Organization, UNESCO 
recent years, with the development of training programmes & World Health Organization 2010). CBR services are 
in a number of African countries, including Ghana, Togo, typically delivered by community workers with general and 
Kenya, Mozambique and Uganda (Wylie et al. 2016). limited training. There is now increasing recognition that a 
range of rehabilitation approaches, including a mix of CBR 
Currently, there is limited documented information about the and more specialised medical rehabilitation services, are 
nature and organisation of the work of SLTs in SSA. essential to provide a holistic model of rehabilitation in the 
Understanding the characteristics of the existing speech and region (Nganwa et al. 2013). This includes increasing the 
language therapy workforce, including the scope of practice, availability of more specialised rehabilitation professionals, 
has potential to assist in the planning and strengthening of including SLTs (Nganwa et al. 2013; World Bank & World 
services (Gupta, Castillo-Laborde & Landry 2011) and allow Health Organization 2011; World Health Organization 2017).
consideration of how this emerging profession contributes to 
rehabilitation services for PWCD in the region. A previous SLT is a Western profession that has evolved within the 
paper (Wylie et al. 2016) described survey results from a rehabilitation frameworks and belief systems of Europe and 
sample of the SLT workforce in SSA, including their North America (Pillay & Kathard 2015; Sherry 2007) and is 
demographic composition, training and experience, and historically associated with medical rehabilitation. SLTs have 
identified patterns suggestive of increasing localisation of the specialised skills in the rehabilitation of communication and 
SLT workforce (i.e. more African nationals rather than swallowing. In the Minority World, SLTs typically work with 
foreigners working as SLTs). In light of the recent growth in both children and adults with a range of communication and 
training of SLTs (Wylie et al. 2016), there is an imperative to swallowing disabilities including primary communication 
ensure the direction of the emerging profession and services disabilities such as speech and language delays or disorders, 
are both appropriate and responsive to the needs in or those secondary to developmental disabilities, such as 
communities they serve. This paper contributes to the debate cerebral palsy, autism and hearing loss. Individuals may also 
about the most appropriate way to develop services for seek communication rehabilitation services for acquired 
communication disability rehabilitation in SSA by describing communication disabilities following a range of health events 
the employment patterns, roles and characteristics of service such as stroke, head injury or head and neck cancer. SLT 
users of a sample of the SLT workforce in the region. services are commonly integrated within multidisciplinary 
rehabilitation teams in the Minority World countries.
Literature review SLTs, with their specialised knowledge in the field of 
Many people with communication disabilities may seek communication disability, are likely to have key roles to 
rehabilitation across their lifetime. In this paper, the term play in communication disability rehabilitation in Majority 
rehabilitation is used to represent: World countries. These roles may include both providing 
a set of measures that assist individuals who experience, or are communication disability rehabilitation for people with 
likely to experience disability, to achieve and maintain optimal acute and complex communication needs and supporting 
functioning in interaction with their environments. (World Bank and training CBR workers and others in providing basic 
& World Health Organization 2011:96) rehabilitation services for PWCD (Wylie et al. 2016). However, 
it is unclear how SLTs currently work in Majority World 
Rehabilitation is cross-sectoral and may involve a wide range contexts, where CBR and medical rehabilitation services may 
of workers in service delivery, including volunteers, CBR coexist.
workers, allied health staff, doctors and family members. It is 
vital that an appropriate range of rehabilitation services are Human resources for rehabilitation are a significant issue 
available, in order to promote participation in work, globally (Gupta et al. 2011; World Bank & World Health 
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Page 3 of 9 Original Research
Organization 2011; World Health Organization 2017). One The final survey contained 186 items and contained both 
of the identified objectives of the WHO Disability Action open and closed questions. The survey took between 45 and 
Plan (2014–2021) (World Health Organization 2015) is 60 min to complete, a significant time commitment for 
to strengthen and extend rehabilitation services, through participants. In order to improve recruitment and response 
development and maintenance of a sustainable rehabilitation opportunities, multiple modes of delivery of the survey 
workforce. It is not the size of the workforce alone that is were offered: online (Survey Monkey), emailed attachment 
critical to improving rehabilitation services. The ways in (form) in Microsoft Word, paper copy or via a telephone or 
which the workforce is organised and supported directly callback service.
impacts the performance of the health system (Chen et al. 
2004). Issues including difficulties achieving a suitable mix Setting
of skills in health workers, inappropriate distribution of 
workers, poor working environments and a lack of ongoing This research was undertaken between April 2012 and 
training may impact the effectiveness of services (Chen et al. March 2013 and sought to recruit SLTs within Anglophone 
2004). There is little documented information on how the countries of SSA. Twenty Anglophone or partially Anglophone 
profession of SLT is organised and supported and the countries were included in the research. South Africa was 
challenges faced by this profession in the delivery of services excluded from the research because of its long history of SLT 
in SSA. education (Pillay & Kathard 2015). Selection criteria included 
self-identifying as an SLT and being resident in one of the 
This paper reports on initial exploratory research into the target countries for 6 months or longer during the study 
profession of SLT in SSA. It presents data describing a sample period.
of SLTs in SSA and provides an overview of their employment 
patterns, work roles and work-related activities undertaken Because of a lack of regional workplace statistics or listings of 
by SLTs. The paper then explores the characteristics of groups professionals, snowball sampling was utilised so that the 
of PWCD who receive services provided by the SLTs researchers could draw on local knowledge of SLTs and other 
surveyed. This paper is the second in a series of two. Its networks in the region to locate potential participants. When 
companion paper (Wylie et al. 2016) previously described the probability sampling methods are not possible, snowball 
demographics, education, professional experience and sampling can be used to access the population under study 
geographical stability of the 33 SLTs who completed the (Handcock & Gile 2011). The inherent risk of bias of this 
survey. sampling methodology is acknowledged.
Research method and design Procedure
Survey research was undertaken to investigate the characteristics, Initial contact was made with a range of potential informants 
work and employment of SLTs across English-speaking who had contact with or knowledge of communication 
countries in SSA. The methodology for this research has been disability services in target countries. Contacts included 
described in more detail in a previous complementary article SLTs, disability workers, voluntary organisations, professional 
(Wylie et al. 2016). The current paper reports on a subset of bodies and academics. Contacts were either known personally 
data from the survey reporting on employment conditions, to the research team or located through Internet searches and 
work roles of the respondents and characteristics of the they, in turn, were asked to forward information about the 
PWCD to whom they provide rehabilitation services. research to potential respondents. General information, 
survey resources, links for completion of the survey and 
Materials contact information were provided to potential participants. 
Paper-based surveys were distributed to eligible SLTs at the 
This research used a purpose-designed survey instrument, East African Conference on Communication Disability in 
developed in line with the process described by Punch (2003). Uganda in 2012.
Survey aims were established across five domains: workforce 
characteristics, SLT education, language and culture, 
employment and work activities, and continuing education. Analyses
Survey items were developed, reviewed and revised by the Raw data from completed surveys were entered into a 
research team who had significant experience as SLTs in Microsoft Excel spreadsheet. Text-based categorical responses 
Majority World settings. Because of resource limitations, the were numerically coded according to a priori categories 
survey was provided only in English. where relevant (e.g. identification of African or non-African 
nationality). Quantitative data were analysed using 
Piloting of the survey was undertaken with six SLTs who descriptive statistics. Small sample sizes precluded use of 
each had experience working in the Majority World. inferential statistical analysis. Data are presented descriptively 
Participants were requested to provide feedback on the and must be interpreted with caution.
content and structure of the survey, including the readability 
of each item. The survey was subsequently modified based Open-ended survey responses were analysed using 
on feedback from pilot participants. qualitative content analysis as described by Shreier (2012). 
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Page 4 of 9 Original Research
Following a period of immersion and key word identification, sector (n = 7, 58%), followed by the private sector (n = 5, 42%) 
codes were developed inductively from the data and (Figure 1). No non-African national in this sample reported 
reviewed during first-pass coding; a coding frame was holding a government-funded job. Small sample size 
developed and applied to the data from each open question. precluded statistical analysis.
Data within each code were reviewed to ensure internal 
consistency. The coding frame and coding were reviewed by Employment setting
a second researcher experienced in qualitative research. Final 
codes were organised into hierarchies. Employment settings indicated the type of service in which 
the respondent provided services. As an example, a SLT 
Results working in a government school would have been considered 
to be employed by the government (funding sector) but 
Thirty-three completed surveys were received from SLTs employed to offer services in schools (employment setting). 
working across nine countries. The demographic mix of 
SLTs were employed in the following settings: non-
respondents is reported in Wylie et al. (2016). Two-thirds of 
n government organisations (n = 15, 34%); private practice the sample (  = 22) identified as African nationals while the 
remaining one-third (n = 11) were non-African nationals, (n = 13, 30%); health services and hospitals (n = 8, 18%); 
predominantly from European countries. education or schools (n = 6, 14%); and tertiary education (n = 
2, 5%). Results organised by funding sector and employment 
setting are presented in Table 1.
Employment and funding sector
All respondents reported currently working, holding at least In an open-ended question about job descriptions, respondents 
one job (mean 1.45, range 1–3, mode 1). Thirty-three described the location of their workplace, including hospitals, 
respondents reported on a total of 44 jobs. Thirty-two jobs schools, special schools, preschools, client homes, private 
were held by 22 African nationality SLTs and 12 jobs were clinics, universities, rehabilitation centres and disability 
held by non-African nationality SLTs. The majority of centres.
respondents held one job only, but one-third (n = 11, 33%) of 
the respondents held more than one job. Employment patterns
The term ‘funding sector’ was used to describe in which Overall, less than half (18 of 44 jobs, 41%) of all jobs were 
sectors SLTs were employed and included government, reported as fulltime. Participants were asked to identify if 
private and not-for-profit (e.g. non-government organisations roles they held were permanent or temporary or to identify if 
and voluntary services) sectors. The largest proportion of SLT the type of role made this irrelevant (i.e. independent 
jobs were in the private sector (n = 20, 45%), followed by the volunteering or self-owned private practice). Overall, of the 
not-for-profit sector (n = 15, 34%) and the government sector 44 jobs, 27% (n = 12) fell into the not relevant category. The 
(n = 9, 20%). (Note: Percentages rounded to the nearest permanency of applicable jobs, by funding sector, is reported 
percentage point.) Qualitative content analysis confirmed in Table 2.
this data. In response to an open-ended question asking 
respondents to describe each job, SLTs frequently identified African naonality respondents
their funding sector, including government, private and non-African naonality respondents
all respondents
not-for-profit groups. Descriptions of organisations that 
70
were considered not-for-profit included: non-government 5860
organisation, not-for-profit, consumer group, international 50 47 42 45
voluntary organisation and Christian mission. 40 34
30 28 25
20
When considered by nationality grouping, the largest 20
10
proportion of jobs held by African nationals (n = 15, 47%) 0
0
were in the private sector, with similar proportions observed Private Government Not-for-profit
in the government (n = 9, 28%) and not-for-profit (n = 8, 25%) Funding sector by naonality grouping
funding sectors. The largest proportion of jobs reported by 
FIGURE 1: Funding sector of speech and language therapy jobs, by nationality 
non-African nationality respondents was in the not-for-profit grouping.
TABLE 1: Speech and language therapy jobs by funding sector and employment setting.
Variables Health Education Tertiary education NGO Private practice Total jobs by funding sector
n (%) n (%) n (%) n (%) n (%) n (%)
Private 5 (25) 2 (10) 0 (0) 0 (0) 13 (65) 20 (45)
Government 3 (33) 4 (44) 2 (22) 0 (0) 0 (0) 9 (20)
Not-for-profit 0 (0) 0 (0) 0 (0) 15 (100) 0 (0) 15 (34)
Total jobs by service setting 8 (18) 6 (14) 2 (5) 15 (34) 13 (30) 44 (100)
NGO, non-government organisation.
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Speech and language
therapy jobs (%)
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TABLE 2: Permanency (applicable roles), overall and by funding sector. TABLE 4: Frequency: age range of speech and language therapy service users.
Variables Permanent Temporary Unsure Total Age range of service users Always or Sometimes Occasionally or 
n (%) n (%) n (%) often n (%) n (%) never n (%)
All applicable jobs 12 (39) 16 (52) 3 (10) 31 Adults (18+ years) 9 (27) 9 (27) 15 (45)
Breakdown by funding sector Adolescents (13–17 years) 10 (30) 11 (33) 12 (36)
Private 4 (36) 7 (64) 0 (0) 11 School-aged children (6–12 years) 21 (64) 9 (27) 3 (9)
Government 6 (75) 1 (13) 1 (13) 8 Preschool-aged children (3–5 years) 26 (79) 6 (18) 1 (3)
Not-for-profit 2 (17) 8 (67) 2 (17) 12 Babies and infants (0–2 years) 4 (12) 8 (24) 21 (64)
Figures rounded to the nearest percentage point. Figures rounded to the nearest percentage point.
TABLE 3: Location of speech and language therapists. TABLE 5: Most frequently reported health-related conditions of people accessing 
Location of SLT n (%) speech and language therapy services.
Capital city 24 (73) Health-related conditions Rank Proportion of SLTs reporting seeing people with this condition ‘always’ or ‘often’ (%)
A city, large town or regional centre (not the capital city) 7 (21) Autism spectrum disorders 1 61
A small town, village or small community 2 (6) Language delay or disorders 2 58
An isolated rural area – but not in a village or community 0 (0) Speech delay or disorders 3 52
Total 33 (100) Intellectual disabilities =4 45
SLT, speech and language therapist. Physical disabilities =4 45
Stroke 6 36
Respondents were asked if there was someone else within Hearing impairment =7 27
the organisation doing similar work (i.e. a professional peer Stuttering =7 27
in SLT or communication disability). Thirty-eight per cent SLTs, speech and language therapists.
(n = 16) of respondents indicated that they worked alongside 
a professional peer. The remaining 62% (n = 26) indicated that Age
they did not have a professional peer within their work Respondents were asked to rate the frequency in which they 
context. worked with people of various ages, using a five-point 
Likert scale. Responses were aggregated to represent 
Recipients of speech and language therapy age groups more and less frequently seen and presented in 
services Table 4. More than half of the respondents (n = 18, 55%) 
Respondents were asked to indicate if their job was ‘clinical’, indicated that they regularly worked with people across the 
involving direct service provision to individuals or groups of age ranges – from children to adults (sometimes, always or 
people with communication disabilities, or had a ‘non- often).
clinical’ (education, community development or programme) 
focus, where they did not work directly with PWCD. The Within the open-ended job description, respondents frequently 
following section reports on the 33 ‘clinical’ jobs described in referred to the age of people using SLT services, with a 
the sample. dominance of paediatric clients reported, consistent with the 
descriptive data.
Geography
SLTs were predominantly located in urban areas including Health-related conditions
capital cities and other towns and cities (94%), with the Respondents were asked to consider the types of health-
majority of SLTs (73%) based in the capital city (Table 3). related conditions experienced by PWCD accessing SLT 
services and to rank how commonly people with these 
Of the jobs described in this study, two urban-based therapists conditions accessed services on a five-point Likert scale. The 
mentioned visits to rural areas within their job descriptions. range of conditions included in the survey were based on the 
observations and clinical experience of the researchers 
‘I work in a project which visits rural and remote areas 
on development and integration for people with disabilities, working in the region and explored during pilot testing. 
especially communication.’ (ID T001, nongovernmental organisation Open categories were included to allow respondents to 
(NGO)/voluntary) represent conditions that were not covered by predetermined 
‘I work all over the country, both in urban and rural categories in the survey.
environments.’ (ID E002, NGO/voluntary)
Results are ranked in Table 5 indicating the eight most 
Within the qualitative content analysis of job descriptions, frequently reported conditions of people accessing clinical 
there was evidence that PWCD travel to receive services and SLT services and the proportion of SLTs who reported seeing 
that travel had an impact on service delivery. people with this condition ‘always or often’. While the list is 
‘Since my clients come from for like 300km I assess, psycho- unlikely to be comprehensive, because of the diverse range of 
educate parents and give advice on further management at clients seen by SLTs, it provides an indication of common 
home, since they can’t stay at the centre.’ (ID PB11, NGO/ issues that are experienced by people who seek rehabilitation 
voluntary) from SLTs in the sample.
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Within the open-ended job description, respondents training others (44%). However, over one-quarter of 
frequently reported seeing people with a variety of different respondents (n = 7) indicated they spent 25% or more of their 
health-related conditions. time training in the workplace (Figure 2). Within the open-
‘I see all patient groups as they come, cannot afford to specialize ended descriptions of training, participants indicated that 
in this kind of work setting where the service is limited.’ (ID they had trained a variety of workers across sectors in the 
E004, NGO/voluntary) previous 12 months (Table 8).
Economics of services Ethical considerations
Respondents were asked to indicate if direct payment was The University of Queensland, Australia, where the 
required for clients to receive SLT services or if services were first author was enrolled as a doctoral student at the time 
free at the point of use. Respondents indicated that almost of the study development, granted ethical approval 
two-thirds (64%) of clients directly paid for SLT services at a for this project (reference number 2011-SOMILRE-0018). 
level perceived by the therapist to be commensurate with Informed consent was inferred via survey response. 
private or commercial rates. The remainder were noted to Secure Sockets Layer technology was used to protect online 
pay either a small or subsidised fee (18%) or to receive a survey data.
service free at point of use (18%). Payment levels, by funding 
sector, are outlined in Table 6. Discussion
This paper reports data from a survey of the work of 
Roles of speech and language therapists SLTs in SSA on employment patterns, position funding, 
A broad range of work-related roles were described by characteristics of clients and activities undertaken by SLTs. 
respondents within the open-ended job descriptions. The Overall, private and not-for-profit sectors were the largest 
categories of roles following qualitative content analysis and employers of SLTs in this sample. African nationality 
examples of the types of activities described are provided in respondents were most frequently employed within the 
private sector, while non-African nationals were most 
Table 7.
frequently employed in the not-for-profit sector. As the 
profession of SLT grows in SSA, not-for-profit organisations 
Training others may consider recruiting SLTs differently from current 
Respondents were asked to specify the amount of time they models of volunteerism (see Hickey et al. 2012). Rather than 
spent training people who were not parents, carers or importing foreign volunteers, they may have capacity 
relatives of clients. Of the 27 responses, the largest proportion to offer longer term employment to locally based SLTs, 
(n = 12) estimated they spent less than 10% of their time on which improves potential for service stability and 
language mix needed for culturally appropriate services 
TABLE 6: Perceived rates of payment, by funding sector. (Wylie et al. 2016).
Variables Private Government Not-for-profit Total
n (%) n (%) n (%) n (%)
50
Private level fees 16 (80) 1 (20) 4 (50) 21 (64) 4445
Small fee 3 (15) 1 (20) 2 (25) 6 (18) 40
Free service 1 (5) 3 (60) 2 (25) 6 (18) 35 30
30
Total 20 (61) 5 (15) 8 (24) 33 (100) 25
20
15 11
TABLE 7: Speech and language therapists: Role categories and examples. 10 7 7
5
SLTs: Role Examples from transcripts of open-ended questions
categories 0 Less than 10 10 - 24 25 - 49 50 - 74 74 - 99
Therapist ‘We do some therapy and advice for families and train families how 
to best work with their children.’ (T001, NGO/voluntary) Time at work (%)
Team member  ‘work closely with OTs, physiotherapists, doctors, audiologists, 
teachers, educational psychologists and psychologists to ensure a FIGURE 2: Proportion of time at work spent training others.
holistic approach to therapy.’ (SM04, private)
Trainer ‘Most of the work is providing training to the carers and parents, and TABLE 8: Examples of groups trained by speech and language therapists.
teaching other professionals and volunteers who work with them 
[and use] the therapeutic strategies.’ (E002, NGO/voluntary) Sector Examples of groups trained in the previous 12 months
Administrator ‘I operate the IEPs and co-ordinate the service.’ (PB15, NGO/ Health Nurses, occupational therapists, physiotherapists, psychologists, 
voluntary) other therapists (unspecified), doctors, SLT assistants, student 
nurses, medical students, nursing students, other SLTs, healthcare 
Facilitator ‘… facilitate three patient/client and carer support/ self-help groups.’ workers (unspecified).
(E001, private)
Disability or CBR workers, community workers, rehabilitation technicians, 
Advocate ‘… advocating for inclusion in the mainstream schools’ (SM11, community community-based trainers (of the deaf).
private)
Education Special education teachers, class teachers, preschool teachers, 
Researcher ‘We also do research on communication disorders.’ (T002, teaching assistants, student teachers, educators (unspecified).
government)
Students SLT students, students (unspecified), neuropsychology student.
Capacity ‘Involving the local people in their capacities as much as possible and 
builder using approaches that can be supported through the culture and Home Care workers, support staff.
resources locally available.’ (E004, NGO/voluntary) Other Workers at other NGOs.
SLTs, speech and language therapists; NGO, non-government organisation. SLT, speech and language therapy; SLTs, speech and language therapists; CBR, community-
Respondent information: (Unique identifier, job funding sector). based rehabilitation; NGO, non-government organisation.
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Training others (%)
Page 7 of 9 Original Research
Part-time and temporary roles dominated the sample. Less consideration. SLTs reported working in multidisciplinary 
than half of roles described (41%) were fulltime and less than contexts and reported a wide range of multidisciplinary team 
half of relevant jobs (39%) were reported as permanent. members, which may provide some level of generic support 
While government jobs were limited, they appeared to offer in continuous learning.
more stability, with the majority of these roles reported 
as permanent. Further investigation around whether Lack of professional support and supervision has implications 
employment patterns reflect job availability or employee for performance of the workforce (Mathauer & Imhoff 2006; 
preference is required. Willis-Shattuck et al. 2008). Potential for career progression 
into more senior positions has also been shown to impact the 
The dominance of part-time and temporary roles prompts motivation of the workforce (Willis-Shattuck et al. 2008). The 
questions about service sustainability. Workforce stability development of appropriate support systems and career 
has been shown to benefit both the service and the client as pathways may contribute to a robust and motivated 
it contributes to both improved productivity and skills workforce.
(Auer, Berg & Coulibaly 2005; Buchan 2010). The high rate 
SLTs reported engaging in a wide variety of roles within their 
of temporary roles, coupled with use of a foreign (non-
work, including the provision of direct therapy as well as 
African) workforce with high turnover (Wylie et al. 2016), 
roles including inclusion support, capacity building and 
indicates that many of the SLT services available may awareness raising, which may reflect a broader role than 
not be stable. Establishment of stable, permanent jobs traditionally seen in SLT (Wickenden 2013). One of the most 
for the growing local workforce is essential if SLT is to common categories in the description of work roles was 
contribute meaningfully to communication disability training others. Respondents reported training a diverse 
services in the region. range of people across sectors. The sector in which SLTs are 
employed may influence the type of roles SLTs undertake, 
The availability of stable jobs for SLTs is particularly including working in areas such as training others, advocacy 
important with the increasing number of training and awareness raising. Broader roles for SLT may be more 
programmes for SLT in SSA (Wylie et al. 2016). Unless a constrained in the private sector, where the focus is likely to 
system of stable jobs is available for SLTs who train in SSA, be on the provision of treatment to individuals.
training programmes may produce graduates who remain 
unemployed in the field, migrate out of the region to seek Training appeared to be a key role for the SLTs in this sample. 
stable employment, change profession, or self-employ Widespread training by SLTs in SSA has the potential to 
through private practice. support models of rehabilitation that use less specialised 
service providers, such as mid-tier health workers and CBR 
Governments have a key role to play in disability, including workers. The ability of SLTs to train and capacity build with 
strategy, policy, regulation, resourcing and delivery of others has been recognised in the literature on development 
rehabilitation services (World Bank & World Health of services for communication disability in the Majority 
Organization 2011). The lack of SLT roles in the government World as essential (Hartley & Wirz 2002; Robinson et al. 
sector is multifactorial. Historically, because of a range of 2003; Winterton 1998).
policy and economic issues, African governments have 
struggled to employ and retain health workers or invest Calls to improve the formal training systems for CBR workers 
sufficiently in health infrastructure (Anyangwe & Mtonga (Mannan, MacLachlan & McAuliffe 2012) offer a timely 
2007). With recent growth in local SLT training (Wylie et al. opportunity to reconsider the roles for a profession such as 
2016) increasing the size of the workforce for communication SLT in Majority World contexts, which may differ from those 
in the Minority World. The dominance of training in job 
disability rehabilitation, it is unsurprising that positions 
descriptions of SLTs suggests that they may be well placed 
are lagging behind in government services. If governments 
(and already engaging) in supporting training in 
in SSA are to ensure a stable, equitable and accessible range communication disability. This is critical in light of the 
of rehabilitation services for communication disability, then recognition of the lack of training for CBR workers in this 
it is important to consider how the workforce with skills in area (World Bank & World Health Organization 2011). Using 
communication disability, including SLTs, should be SLTs – who possess specialist skills in communication and 
employed and what it will take to drive such a change. swallowing disabilities – to train and support CBR workers, 
Substantial activism may be required to produce policy and other health and education workers, has the potential to 
shifts that prioritise communication disability and establish both increase the coverage of communication disability 
SLT roles in the government sector (Wickenden 2013; rehabilitation and improve networks between health-related 
Wylie et al. 2013). rehabilitation and CBR (MacLachlan, Mannan & McAuliffe 
2011; Mannan et al. 2012; Nganwa et al. 2013; World Bank & 
The majority of SLTs (62%) reported that they did not have a World Health Organization 2011).
SLT colleague within their workplace. As the profession 
grows, how SLTs are supervised, mentored and supported to SLTs reported providing services to a range of people with 
enable continuous learning and service quality requires communication disabilities, including people across the 
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Page 8 of 9 Original Research
lifespan and with a range of health-related conditions. The may limit the ability of an individual to maximise his or her 
focus of services appeared to be predominantly in paediatrics, social and economic independence (Ruben 2000).
although respondents reported seeing clients across the age 
ranges. Limitations of the study
The most frequently reported health-related conditions of This is an initial exploration of the SLT workforce with limited 
people seeking SLT services were speech or language delay data. Non-probability sampling methods and a small sample 
or disorders, autism spectrum disorder, physical disabilities size limit the ability to generalise results. Selection bias was 
and intellectual disabilities. The data indicated that many of likely, as despite the use of multiple response modalities, 
the SLTs sampled work across a range of areas in a generalist respondents may have been more likely to respond if they 
approach, in contrast to countries of the Minority World, had access to technology or were more connected in the 
where services and systems are well developed and therapists international or local communication disability networks. 
often work in specialised or specific areas of practice. However, this study offers an early exploration of a sample of 
the workforce and consideration of important factors of 
The generalist nature of the roles described in this sample, relevance to the profession in the region.
with SLTs working in both adult and paediatric populations, 
and across different health-related conditions, indicate that Conclusion
SLTs require a diverse range of support to maintain and grow Speech and language therapy is beginning to grow in SSA 
skills through continued professional education. Creating with the development of local SLT training programmes 
alternative networks of support and supervision to meet the (Wylie et al. 2016). It is timely to reflect on how the profession 
needs of SLTs working with diverse caseloads is particularly of SLT could and should be organised in SSA, particularly 
important as the majority of respondents reported being the if the aim of expanding the profession is the development 
only SLT in their workplace. of sustainable and equitable communication disability 
rehabilitation services. This research presents the workforce 
Services provided by SLTs in the sample were largely profile of a sample of SLTs in SSA by describing their 
provided in urban areas with limited services in rural employment patterns, selected characteristics of people 
communities. This is consistent with the maldistribution of receiving SLT services and work roles. Services provided by 
the health workforce between rural and urban settings in SSA SLTs were provided to PWCD across age ranges, health 
(Anyangwe & Mtonga 2007) and represents a geographical conditions and settings, with paediatric, urban services 
barrier to SLT service access (Peters et al. 2008). commonly reported. Training was a commonly reported role 
for SLTs in the sample. Consideration of employment, work 
The cost of services has been shown to be one of a range of and service factors has raised a number of issues around how 
barriers to accessing health services (Commission on Social SLTs are employed and work in the region, which may impact 
Determinants of Health 2008; Mills et al. 2012; Peters et al. 2008), service sustainability and accessibility.
particularly when repeated or expensive treatments are 
required (Ansah et al. 2009; James et al. 2006), such as in the While this research has provided initial insights into the role 
case of rehabilitation services. and employment of SLTs and indications of who receives 
services in the region, much more extensive debate and research 
Almost two-thirds of SLT service users were reported to pay is required to consider how the work of SLTs in SSA should be 
fees commensurate with a private level of service. Payments structured and supported. Reconsideration of the role of SLTs is 
at this level were reported across private, government and needed to ensure that SLTs contribute to sustainable and 
not-for-profit employment sectors; however, the small accessible communication rehabilitation in a way that is 
amount of data was suggestive of government SLT services responsive to the rehabilitation needs of people in SSA.
levying lower direct costs to PWCD. This requires further 
exploration as costs of services may present an economic Acknowledgements
barrier to equitable rehabilitation (Peters et al. 2008). While 
governments in Majority World countries are challenged in The authors thank the participants for their generous 
financing rehabilitation (World Bank & World Health commitment of time in contributing to the lengthy survey.
Organization 2011), creation of SLT roles in sectors with free 
or low-cost services or models of coverage for PWCD is Competing interests
essential to promote equity of access to rehabilitation. As SLT The authors declare that they have no financial or personal 
training programmes develop, if graduate SLTs are siphoned relationships that may have inappropriately influenced them 
into a system of private practice, possibly contributed to by a in writing this article.
lack of government jobs, there is a risk of further promoting 
inequality, where more affluent urban residents are 
disproportionately able to access SLT services. Lack of access Authors’ contributions
to rehabilitation may have long-term implications for people K.W. was the principal researcher on the project as part of her 
with communication disabilities as communication disability doctoral studies and wrote the majority of the manuscript. 
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Page 9 of 9 Original Research
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