Most humanitarians I meet aim for sustainability in their programs. They hope that one day their project will support itself and continue to grow with backing from the community. Most start their work because they see an unmet need and feel compelled to find a way to help. Armed with the best of intentions, they form a plan based on what they believe is lacking in a community. To meet the need, they bring in outside resources after which they begin finding local partners. While these projects usually begin with gusto, they tend to fizzle out as community members contort to fit into the model designed by an outsider. Control remains external to the community as founders struggle to let go or find leaders inside the community to pick up the mantel. Audiology is a growing field in Kenya and has drawn many people from around the world who want to help establish clinics and programs. At AIC Kijabe Hospital, our team has spent the last five years establishing an audiology clinic using asset-based community development principles that will allow us to transition it to a Kenyan-led clinic by the end of this year. In sharing some of our hard-learned lessons here, I hope to encourage those who want to help improve hearing health care around the world.
ISSUES WITH A NEED-BASED MODEL
One model of humanitarian work is referred to as need-based community development. In the audiology world, this model appears in projects where short-term teams fit hundreds of hearing aids without first contacting local stakeholders or seeking to train local people to provide follow-up care. This is discouraging for those who are already working to bring audiology services to a place but were not contacted to be involved. In addition, those who damage their hearing aids (e.g., children who accidentally break their hearing device) will have no hope for repair or replacement until the next team arrives. The need-based model is followed when we give hearing aids away for free and, in the process, disrupt community systems that work remarkably well to support those who have need. The culture of collective responsibility and generosity, where neighbors invest in a child with hearing loss by contributing to his treatment, is bypassed when it is assumed that a community does not possess the ability to help (TEDx, 2016 http://bit.ly/2O7c3t0). Communities are left feeling deficient and inadequate to help themselves. Though aiming to help a community, we can leave it feeling powerless instead (UN-HABITAT, 2008 http://bit.ly/2O5KfoD).
I will confess seeing my work in Kenya through a need-based lens when I moved here in 2013. I was one of only a handful of audiologists in a country with 6 million people with hearing loss. They needed me, right? Wrong. I was fortunate to be surrounded by very patient Kenyan colleagues and seasoned missionary humanitarian workers who taught me a better way early on in my time here. I spent my first three months in clinical practice listening to those people, learning effective ways to help, and figuring out that my idea of helping would eventually burn me out while doing far more harm to my patients and their families in the end. I learned that using the principles of asset-based community development (ABCD) is far more effective in establishing programs that will have a long-term, positive impact on a community. Our team at Kijabe has not done this work perfectly. We continue to refine and adjust, but we are striving toward a more community-oriented approach.
The following questions have been an ongoing discussion as our hospital determines how to offer audiology services to our patients:
- Who are the key stakeholders for audiology in Kenya? Are there Kenyan-led initiatives to develop audiology in Kenya? If not, why? Can we be a part of those initiatives? Will anything we are doing hamper or damage the reputation of audiology or the long-term work already occurring? Would I be angry if someone began a program like mine in my city?
- Can someone else do my job? Is there a Kenyan member of our staff who is interested in audiology as a profession? Can we help with training opportunities? Can we plan to set them up as the leader from the start?
- How should we handle payment for hearing tests, hearing aids, earmolds, and batteries? What are the typical ways patients would pay for their medical needs? Is there a compelling reason to disrupt the community's normal way of helping its needy members to offer our services for free? Will our model help us form a sustainable program or will it leave the hospital and patients consistently dependent on outside help?
- What happens if I have to move back to the United States/cannot make short-term trips anymore? Have I removed myself from the primary position so that someone else is in charge and does most of the work?
- Have I asked enough questions?
INCORPORATING THE ABCD PRINCIPLES
While there are many factors to consider in answering the questions above, we will focus on local buy-in and financial considerations.
The first goal we set when the audiology clinic opened in January 2014 was to establish partnerships with other key stakeholders in hearing health care in the country. The primary partnership has been with the University of Nairobi and Kenyatta National Hospital. We wanted to be sure that any long-term program we implement can fold in the students graduating from this program and set them up to lead in the future. Because audiology is a newer field in Kenya, the government does not have strict regulations on its practice. However, audiologists in Kenya are striving toward recognition by the government, including licensure, and one of our biggest concerns is that we conduct our practice in a way that makes that process easier. It is vital that outside practitioners not hinder the work of people who will remain to do this work long after we have left.
Another piece of the local buy-in side has been identifying existing staff members who could be a part of building the audiology program. An assistant in an ENT clinic showed some interest in audiology and spent four years learning through practical teaching and online training courses. She is expected to take over leadership of the audiology program in October 2018. This is not a traditional way of training audiologists. Because of the limited access to formal programs and the need to work within the schedule of an employee who does not have the option to quit her job and become a full-time student, we had to find a creative way to build her skills. Audiologists from Western nations may have the idea that only professionals with their level of training are capable of providing quality care. This attitude can make it difficult or impossible to hand over full responsibility to local people. Certainly, we should continue to develop training programs and train local audiologists at the highest levels, but we must also find ways to get quality hearing health care to more people using non-traditional ways of training. The most important factor for us has been our technician's willingness to learn and grow. It has also required me to step away from clinical duties slowly over time and allow her to work independently. Each time I am away from the clinic for a few days or months, her skills and confidence grow exponentially.
ENSURING LONG-TERM SUSTAINABILITY
Perhaps the biggest challenge for humanitarian audiologists is deciding how to handle paying for hearing aids. Many programs give them away for free. The heart behind this is admirable, but I would like to challenge the idea that it is the best or only model, especially in the African context. In Kenya, community fund-raising is a common way to cover expenses for important events. The word used to describe this is harambee. In Swahili, this word means “all pull together” and the concept is so important to Kenyan culture that it appears on its coat of arms. During harambee events, communities come together to raise money to help pay for weddings, funerals, hospitalizations, school fees, and whatever other needs may come up among neighbors and families. It is a beautiful and an expected part of life that expresses a community's investment in its members.
When Westerners begin working in developing countries with the expectation that no one can possibly afford a hearing aid, we search for solutions that come at no cost to the patient and tend to bypass some of these important social safety nets that are a part of these cultures. Again, the desire to be helpful is noble and I do not want to diminish it. However, in giving away devices, we disrupt the normal social structure and possibly prevent valuable community buy-in to a project or a specific person with hearing loss. Consider how different a child's integration into community might be if his neighbors have pulled together to help purchase his hearing aids. Families have opportunities to become community ambassadors for hearing loss and disability by leveraging this shared investment. In our experience, about half of our patients raise the full cost of the hearing aids within one month. These payments allow us to pay salaries and keep our clinic open. Hundreds of free hearing aids and amplifiers introduced to the market actually slow down our path to self-sustainability and leave Kenya reliant on outside donations for longer than might be necessary.
There are certainly instances where families and communities cannot afford the full cost of a hearing aid. At our hospital, we fit new hearing aids almost exclusively. We always ask families to attempt to raise at least a portion of the cost. In cases where the entire cost is not available, we have two options. The first is to access our hospital's needy patient fund to subsidize the cost for these families. Each family goes through a vetting process and is required to provide evidence of financial need. This is completely detached from our clinic, and I (an American) have nothing to do with the decision-making. With only a handful of exceptions in five years, every patient pays something. Our second option is to fit the patient with a donated refurbished hearing aid. These are much less expensive, but come without warranties and with fewer features. Again, we do ask patients to pay a fitting fee with these devices. Patients also purchase their hearing aid batteries. The batteries are donated to the hospital, so we are able to offer them at a substantially discounted rate, but in asking them to pay for their own batteries, we make them ongoing partners in their hearing health care and not simply passive recipients. There was a time in the hospital's history when free hearing aids and batteries were offered. We have found far greater responsibility and ownership among those with hearing loss by expecting financial partnership as well. Fewer hearing aids are lost (only one of about 300 fit in the last five years) and patients return for regular check-ups more consistently.
Sustainable programs require stable financial resources to continue. The current model of providing free hearing aids to every patient will not result in self-sustaining, long-term programs. It also disrupts an important social safety net that ties communities together and offers families an opportunity to educate and involve community members in the life of a person with hearing loss. Western workers can consider ways to remove themselves from decision-making about financial need and ask local social workers for help in determining which patients need subsidies. Self-sustainability also requires the involvement of local people to continue the work. I would encourage those who are establishing humanitarian programs to first ask who else is doing this work in a country and find out how they can partner and encourage already established clinics and training programs. Before offering what you think they need, ask them what they would like help with. The answer might be different than you think, and by listening first, the return on investment of time or financial resources is likely to be far greater.