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GLOBAL HEALTH JOURNAL 2026

A u d i o l o g y i n Fo c u s : S t r e n g t h e n i n g G l o b a l E a r a n d Hearing Care Systems

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GLOBAL HEALTH JOURNAL 2026

A u d i o l o g y i n Fo c u s : S t r e n g t h e n i n g G l o b a l E a r a n d Hearing Care Systems

Published in 2206 for ENT UK Global Health Compiled by: Cheka Spenser For information please contact: Cheka Spencer Globalhealth@entuk.org Designed and Printed by: www.beamreachuk.co.uk

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contents ENT UK Journal of Global Health

Editor’s note (Cheka Spencer)

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Mission & Role of ENT UK Global Health Global Health Committee Members BACO 2026 GLOBAL SURGERY SESSION Social Justice Through Global Surgery Strengthening ENT Education in Zimbabwe through Otoscopy The Evolution of ENT and Audiology Services in Rwanda Setting up a sustainable hearing health clinic at St Francis de Sales School, Jinja, Uganda #BecauseIHearILive: Supporting deaf children across continents FREE PAPER PRIZE WINNERS – BACO 2026 Winner Runner-Up Acknowledgements

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editor’s note It is a pleasure to introduce this edition of the ENT UK Global Health Journal under the theme “Audiology in Focus: Strengthening Global Ear and Hearing Care Systems.” The contributions in this issue highlight a shared global challenge: how to deliver equitable, sustainable hearing care across diverse and often resource-limited settings.

Across different contexts, a clear narrative emerges — hearing health systems are strongest when they are locally led, decentralised, and built around training and workforce development. From newborn hearing screening in Africa, to district-level ENT services in Rwanda, and otoscopy training initiatives in Zimbabwe, these articles demonstrate how strengthening foundational skills and services can transform access to care.

This edition also highlights the importance of reaching underserved and vulnerable populations, including refugee communities where ear disease is common but access to specialist care is limited. Alongside this, work on rehabilitation and inclusion reminds us that effective hearing care extends beyond diagnosis to communication, education, and social participation.

Taken together, the contributions in this journal reinforce a central message: sustainable improvements in hearing health depend not only on technology, but on investment in people, systems, and long-term partnerships.

We hope this edition stimulates continued collaboration and innovation in global audiology and ENT care.

Cheka R. Spencer Chair, ENT UK Global Health Committee Consultant Rhinologist, ENT Surgeon Clinical Director ENT and Audiology, Orthodontics and OMFS, Phlebotomy and Outpatients Royal Free London NHS FT

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mission Global Health ENT UK is committed to develop high-quality, sustainable care in the specialty across the world, with the hope that equity in health care can be achieved for all.

In particular, there is a focus on low resource countries where there is a lack of appropriate resource and a high burden of disease.

The main aims are to highlight the importance and prevalence of ENT disease on the global stage, with a particular focus on training, such that low resource countries can become self-sufficient in providing their own ENT services.

Such training will be achieved through access to educational resources and support of in-country training through courses and 'camps'.

role ENT UK Global Health committee seeks to cultivate and encourage the ENT UK membership to participate in activities that assist the provision of optimal care of ENT/Head & Neck diseases around the world.

It aims to do so by: • • • • • •

Developing a network of enthusiastic members and international opportunities and resources to be included in a database.

Forging partnerships with local and internal charitable organisations

Encouraging trainees to develop an interest in undertaking international global health fellowships.

Developing organisational links with medical and surgical groups to encourage and enhance the breadth of global health activities available to ENT UK members.

Providing educational resources to low income countries through courses and camps.

Assist in the provision of medical equipment and technology to optimise ENT care in low income countries.

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Global Health Committee Members 2024-25 Nicholas Eynon-Lewis - Chairman of the Global Health Committee

Cheka Spencer - Vice Chairman of the Global Health Committee

Dulani Mendis - Treasurer of the Global Health Committee & Committee Member

Matthew Clark - Global Health Committee member

Sanjiv Kumar - Global Health Committee member

Sanjay Verma - Global Health Committee member

Rachael Collins - Global Health Committee member and secretary

Leye Oyelekin - Global Health Committee member

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Global Health Committee Members 2024-25 Kate Stephenson - Global Health Committee member

Emma Stapleton - Global Health Committee member

Matt Lechner - Global Health Committee member

Catherine De Cates - Global Health Committee member

Anoushka Vindlacheruvu - Global Health Committee member

Farizeh Jashek-Ahmed - Global Health Committee member

Aurelien Gueroult - Global Health Committee member

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Your attendence is requested at the...

BACO 2026 GLOBAL SURGERY SESSION Social Justice Through Global Surgery Friday 3rd July | 09:00–10:30 BACO 2026 | Hybrid Session (In-person & Virtual)

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KEYNOTE LECTURE Professor Johan Fagan

Emeritus Professor of Otolaryngology University of Cape Town, South Africa

ABOUT THE SESSION Join us for a landmark Global Surgery session at BACO 2026 exploring Social Justice in ENT and Global Health.

Professor Fagan will deliver a keynote lecture reflecting on over 30 years of experience in surgical training, capacity building, and health systems development across Africa. The session will highlight how sustainable global partnerships can strengthen training, expand access to knowledge, and promote equity in surgical care.

A chaired panel discussion will follow with leaders in ENT UK Global Health.

WHY ATTEND? This session is designed for ENT surgeons, trainees, educators, researchers, and global health professionals interested in: • • • •

Global surgery and health equity Workforce development Surgical education and training International collaboration

REGISTER & ATTEND Scan this QR code to register and attend this session (in-person or online)

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GLOBAL SURGERY & EDUCATION

Strengthening ENT Education in Zimbabwe through Otoscopy Dr Sean M. Daniel Affiliations: Oxford University Hospitals NHS Foundation Trust, Oxford, UK; University of Oxford, Oxford, UK Role: Doctor; DPhil Candidate (University of Oxford); Recipient, ENT UK Global Health Grant 2026 (Global Health Project Lead: Strengthening ENT Education in Zimbabwe through Otoscopy)

Background Unaddressed hearing loss in Africa remains a major public health concern, with an estimated 40 million individuals living with some degree of hearing impairment, contributing to an economic burden of approximately US$27.1 billion annually in excess costs and lost productivity.

due to preventable causes, including infections and common ear diseases.

However, robust epidemiological data on the burden of ear disease across sub-Saharan Africa remain limited, and formal hearing screening programmes are absent in most countries.

Among children in lowand middle-income countries (LMICs), approximately 75% of hearing loss is

Access to structured ENT training and diagnostic equipment is uneven across healthcare systems, constrained by a shortage of ENT specialists (with a reported density of 0.18 ENT surgeons per 100,000 population in Southern

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Africa), limited infrastructure, financial barriers, task shifting, and a lack of trained teaching personnel. As a result, patients often experience significant delays in diagnosis and referral.

In Zimbabwe, ENT services are concentrated in tertiary centres, and the system relies heavily on medical officers at district hospitals to identify and refer patients with ENT pathology in a timely manner.

As part of the Global Surgery team at the University of Oxford, and with support from the ENT UK Global Health Committee, we organised a teaching visit to the University of Zimbabwe in Harare to explore practical approaches to strengthening ENT clinical skills training for final-year medical students prior to their deployment as medical officers.

Ahead of the visit, it became clear that while enthusiasm for ENT teaching was high, access to structured teaching time and diagnostic equipment was limited. The final-year cohort rotates through surgical specialties in groups of approximately 40 students, with only one dedicated ENT teaching day per week during an eight-week surgical block. Within these constraints, we focused on delivering interactive, casebased teaching centred on practical skills required in early clinical practice.

Otoscopy One core skill rapidly emerged as a priority: otoscopy. Teaching otoscopy to large groups presents an inherent challenge. With traditional otoscopes, the supervising clinician cannot see what the learner sees, limiting realtime feedback and shared learning. For 16

students with minimal prior exposure, this can hinder confidence and diagnostic accuracy.

To address this, we collaborated with TympaHealth, a London-based health technology company, which generously provided two video otoscopes for use during the teaching visit. These devices allow live transmission of the otoscopic image to a screen, enabling both learner and supervisor to view findings simultaneously. Following a brief orientation, the devices proved intuitive and easily integrated into teaching sessions.

Trip to Zimbabwe Teaching sessions were held at Parirenyatwa Hospital, Harare, and delivered to a cohort of 40 final-year medical students. Following casebased tutorials and emergency ENT scenarios, dedicated video otoscopy sessions were conducted.

A show of hands confirmed that none of the students had previously used an otoscope, reflecting the limited availability of diagnostic equipment in routine training environments.

Students were divided into small groups and rotated between clinician and patient roles. The shared-screen capability of the video otoscopes proved transformative.

For the first time, supervisors and students were able to visualise the tympanic membrane together, discuss anatomical landmarks in real time, and identify both normal and pathological findings collaboratively.

Several students identified incidental external and middle ear findings ENT UK GLOBAL HEALTH JOURNAL 2026

during peer examination, prompting discussion around diagnosis, clinical significance, and referral pathways.

Despite the large group size, all students were able to gain hands-on experience.

The energy and engagement were notable, with many students remaining after formal teaching had ended. The video otoscope facilitated a form of shared learning that traditional equipment could not easily achieve, combining supervision, peer learning, and self-directed exploration.

Future Directions Following the success of the initial visit and positive feedback from both students and faculty, we have built on this foundation to support longer-term sustainability.

Although video otoscopes cannot be provided at scale to all trainees, we have purchased eight traditional otoscopes with the intention of distributing them to teaching faculty at the University of Zimbabwe. This will enable continued integration of otoscopy training

Final Year Medical Students ENT UK GLOBAL HEALTH JOURNAL 2026

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into undergraduate teaching and support medical officers beyond their undergraduate training period.

The Oxford University Global Surgery Group (OUGSG) for guidance and support throughout the project

Future visits are planned to further develop this programme, strengthen ENT education, and generate evidence to inform scalable approaches to ENT training across Zimbabwe and subSaharan Africa.

The ENT Department and faculty at the University of Zimbabwe for their warm welcome, enthusiasm, and commitment to medical education

Conclusion This project highlights that meaningful progress in global health education does not always require complex infrastructure. Appropriately designed, accessible technology can rapidly enhance clinical skills training in resource-limited settings.

Equipping future clinicians with core ENT examination skills, alongside access to basic diagnostic tools, has the potential to improve early identification and management of ear disease. Strengthening frontline capacity through practical training and sustainable innovation remains a highly effective strategy for improving global ear and hearing health.

Acknowledgements We are grateful to: The ENT UK Global Health Committee for financial support, which made this visit possible TympaHealth for generously providing video otoscopes for use during the teaching sessions

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ORIGINAL RESEARCH & GLOBAL SYSTEMS

The Realities of Systematic Newborn Hearing Screening in Africa Universal newborn hearing screening is well established in many high-income countries, enabling early identification and intervention for congenital hearing loss. In this review, Professor Marie Josée Tanon-Anoh examines the current realities of newborn hearing screening across Africa, drawing on multi-country experience from West and Central Africa. She highlights marked disparities in coverage, the predominance of pilot and urban-based programmes, and the key barriers to scale-up, while demonstrating that systematic screening is feasible when integrated into existing health systems and supported by sustained local engagement and resources.

Professor Marie Josée Tanon-Anoh Affiliations: Service ORL et CCF, Hôpital Mère-Enfant de Bingerville, Côte d’Ivoire; Département de Chirurgie et Spécialités, UFR Sciences Médicales d’Abidjan (SMA), Université Félix Houphouët-Boigny, Abidjan, Côte d’Ivoire Role: Consultant Otorhinolaryngologist (ENT Surgeon); Academic staff member, Université Félix Houphouët-Boigny; Head of ENT and Cervico-Facial Surgery Service, Hôpital MèreEnfant de Bingerville

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Introduction Hearing loss is one of the most common congenital conditions, with an incidence of 1 to 3 per 1,000 live births in well-baby populations. Permanent sensorineural hearing loss can have a significant impact on child development, particularly on speech and language acquisition [1].

In infants, most congenital hearing loss cases can be identified through newborn hearing screening (NHS). However, certain forms of congenital hearing loss, particularly progressive types, may not be detected until later in childhood [1].

Several medical and scientific societies worldwide, particularly in high-income countries, recommend early screening for hearing impairment before 3 months of age, systematically coupled with timely intervention, ideally before 6 to 9 months of age. Most industrialised countries have implemented universal or regional programmes, some as early as the 1990s in North America [1,2].

In France, universal neonatal hearing screening became mandatory nationwide in 2012 [3].

However, systematic hearing screening is not implemented in most low-income countries. Only a limited number of initiatives led by specialists or scientific societies exist, covering a small proportion of newborns.

In Africa, NHS coverage remains low despite several studies demonstrating its feasibility under local conditions [4,5]. This article reports on experiences and outcomes of newborn hearing screening in several African countries, highlighting their specific characteristics and implementation challenges.

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Current situation of newborn hearing screening in Africa Data are limited, heterogeneous, and often lack standardisation. In a study by Hatzopoulos et al. (2004–2024) [6], which evaluated NHS practices across nine African countries, the authors concluded that data on universal neonatal hearing screening (UNHS) in Africa remain extremely scarce, despite progress over the past two decades. To date, no country in Africa has established a national public health programme for NHS, and existing screening initiatives are largely restricted to major urban centres [6].

Data from the World Health Organization (WHO) indicate that newborn hearing screening initiatives have been reported in 13 African countries. Screening is predominantly hospital-based.

The pooled incidence of congenital or early-onset hearing loss is estimated at 5.27 per 1,000 live births, with marked regional variation. For example, reported incidence reaches approximately 5.5 per 1,000 live births in South Africa and 28 per 1,000 live births in Nigeria [7].

According to WHO epidemiological data, neonatal-specific prevalence data are lacking for most West African countries, with the exception of Côte d’Ivoire. In this country, the estimated prevalence of neonatal hearing loss is 4.4 per 1,000 live births (Fig. 1a). In Central Africa, data are available for only two countries: Gabon (15 per 1,000 live births) and the Central African Republic (10 per 1,000 live births) (Fig. 1b) [7].

In Uganda, Seguya et al. reported a prevalence of hearing loss of 12 per 1,000 infants (4/334) in a hospital-based study [5].

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Africa, data are available for only two countries: Gabon (15 per 1,000 live births) and the Central African Republic (10 per 1,000 live births) (Fig. 1b) [7].

Fig. 1a: WHO data in West Africa

Fig. data in Central Africa Fig. 1a:1b: WHOWHO data in West Africa

Fig. 1b: WHO data in Central Africa

In Uganda, Seguya et al. reported a prevalence of hearing loss of 12 per 1,000 in in a hospital-based study [5]. the organisation of low-risk deliveries Newborn hearing screening initiatives in West Africa

In Côte d’Ivoire, a pilot study conducted in Abidjan in 2009 assessed the feasibility of neonatal hearing screening. Due to

in peripheral maternity units and short postnatal hospital stays (6–8 hours), screening was conducted in vaccination centres. The Bacillus Calmette–Guérin (BCG) vaccine, administered between

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Newborn hearing screening initiatives in West Afr

In Côte d’Ivoire, a pilot study conducted in Abidjan in 2009 assessed the feasibil neonatal hearing screening. Due to the organisation of low-risk deliveries in peri

day 2 and day 7 of life, provided an opportunity for follow-up screening.

Three service delivery models were developed:

A two-stage otoacoustic emissions (OAE) protocol was used. The prevalence of permanent hearing loss was approximately 6 per 1,000 live births [4].

•

Peripheral screening centres: located in vaccination centres and maternal and child health units within general, regional, and university hospitals. Two pathways were used depending on risk status (healthy and sick newborns).

•

Decentralised diagnostic centres: located in secondary-level hospitals, including ENT departments, incorporating diagnostic auditory brainstem response (ABR) testing.

•

Tertiary paediatric care centre: based at Hôpital Mère-Enfant de Bingerville, providing full diagnostic assessment including behavioural audiometry, impedance audiometry, ABR, and auditory steady-state response (ASSR).

Following this pilot study, and in the absence of state funding or a formal institutional framework, a three-year hearing screening project was initiated in 2019 in collaboration with international partners. Following implementation in Côte d’Ivoire, the programme was extended to five additional West African countries: Benin, Burkina Faso, Guinea, Mali, and Senegal.

The screening protocol was standardised across all participating countries. A twostage transient evoked otoacoustic emissions (TEOAE) protocol was used for well babies, while a combined protocol (initial OAE followed by automated auditory brainstem response (AABR)) was used for newborns admitted to neonatal intensive care units (NICU). The screening pathway implemented in Côte d’Ivoire is summarised in Figure 2.

Findings from Côte d’Ivoire are shown in Figure 3.

In Côte d’Ivoire, 4,832 newborns were screened out of 76,922 live births (6.28%), of whom 1,482 screened positive,

Fig. 2: Screening pathway

Three service delivery models were developed: 24



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Peripheral screening centres: located in vaccination centres and maternal and child health units within general, regional, and university hospitals. Two pathways were used depending on risk status (healthy and sick newborns).

Fig. 3: Coverage rates for neonatal hearing screening by project year

In Côte d’Ivoire, 4,832 newborns were screened out of 76,922 live births (6.28%), of whom 1,482 screenedpossible positive, suggesting possible suggesting hearing loss.

Thishearing loss. This low coverage was attributed to multiple factors, including short postnatal hospital stays (6–8 hours), the need for ENT teams low coverage was attributed to multiple to travel to vaccination centres, and equipment limitations (one combined TEOAE/AABR factors, short postnatal hospital device perincluding site). stays (6–8 hours), the need for ENT teams tocontrast, travel intoBenin, vaccination centres,were andscreened out of 26,868 live births (84.62%), In 22,736 newborns equipment the limitations (one rate combined representing highest coverage within the project, as reported by Avakoudjo and Adjibabi.

Although the screening TEOAE/AABR device per site).protocol was similar across countries, strong engagement of clinical and paramedical teams was a key determinant of success.

In contrast, in Benin, 22,736 newborns Across Africa, coverage for newborn hearing screening remain low. In contrast, highwere screened out ofrates 26,868 live births income countries such as France (97.6%) and China (86.5%) report substantially higher (84.62%), representing the highest coverage rates [3,7,8]. In most African countries implementing screening programmes, coverageremains rate below within1%the project, [7]. as coverage of newborns reported by Avakoudjo and Adjibabi.

Although the screening protocol was similar across countries, strong engagement of clinical and paramedical teams was a key determinant of success.

Across Africa, coverage rates for newborn hearing screening remain low.

In contrast, high-income countries such as France (97.6%) and China (86.5%) report substantially higher coverage rates [3,7,8]. In most African countries implementing screening programmes, coverage remains below 1% of newborns [7].

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Conclusion

References

Systematic newborn hearing screening is feasible in African settings. Experience from several countries demonstrates that implementation is possible under local conditions. However, major gaps remain in relation to equipment availability, workforce capacity, and health system integration.

1

Lawrensia S, Gomez Pomar E. Newborn Hearing Screening. 2023. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan–. PMID: 32809765.

2

Patel H, Feldman M. Société canadienne de pédiatrie, Comité de la pédiatrie communautaire. Le dépistage universel des troubles de l’audition chez les nouveau-nés. Paediatr Child Health. 2011;16(5):306-10. doi: 10.1093/ pch/16.5.306

3

Denoyelle F, Rouillon I, Alvin F, Parodi M, Couloigner V, Loundon N, Garabedian N. Le dépistage néonatal de la surdité. Med Sci (Paris) 2021 ;37(5) :519-27.

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Tanon-Anoh MJ, Sanogo-Gone D, Kouassi KB. Newborn hearing screening in a developing country: results of a pilot study in Abidjan, Côte d'ivoire. Int J Pediatr Otorhinolaryngol. 2010;74(2):188-91. doi: 10.1016/j.ijporl.2009.11.008

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Seguya A, Bajunirwe F, Kakande E, Nakku D. Feasibility of establishing an infant hearing screening program and measuring hearing loss among infants at a regional referral hospital in southwestern Uganda.

PLoS One. 2021 Jun 17;16(6):e0253305. doi: 10.1371/journal.pone.0253305. PMID: 3413895.

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Hatzopoulos S, Cardinali L, Skarzynski PH, Zimatore G. The Otoacoustic Emissions in the Universal Neonatal Hearing Screening: A Scoping Review Update on the African Data (2004 to 2024). Children (Basel). 2025. 27;12(2):141. doi: 10.3390/ children12020141. PMID: 40003243

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World Health organization (WHO). Status report on ear and hearing care in the WHO African Region. Brazzaville: WHO African Region, 2024. Available on : https://www.afro.who.int/publications/ status-report-ear-and-hearing-care-who-african-region

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Yuan X, Deng K, Zhu J, Xiang L, Yao Y, Li Q, Li X, Liu H. Newborn hearing screening coverage and detection rates of hearing impairment across China from 2008-2016.

BMC Pediatr. 2020 Jul 30;20(1):360. doi: 10.1186/s12887-020-02257-9.

Current initiatives are largely driven by individual clinicians and external partnerships rather than national policies or sustainable government funding.

Strengthening institutional frameworks, improving resource allocation, and integrating newborn hearing screening into existing maternal and child health programmes will be essential to expand coverage and improve early identification of hearing loss across Africa

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The Evolution of ENT and Audiology Services in Rwanda Rwanda, the “Land of a Thousand Hills,” has seen significant progress in ENT and audiology care over the past two decades, driven by national planning, workforce expansion and decentralisation of services. In this reflection, Dr Kaitesi Batamuliza Mukara describes the evolution of ear and hearing care in Rwanda alongside the establishment of Humanhood Clinics in Kigali, highlighting both system-level development and the realities of building specialist services in a resourcelimited setting.

Dr Kaitesi Batamuliza Mukara Affiliations: Humanhood Clinics Ltd, Kigali, Rwanda Role: Consultant Ear, Nose and Throat Surgeon; Audiologist; Founder and Clinical Director, Humanhood Clinics Ltd; Academic and Public Health Specialist (ENT and Audiology)

Introduction Rwanda has made remarkable progress in the development of Ear, Nose, Throat (ENT) and audiology services over the past two decades. From a setting where specialist capacity and infrastructure were extremely limited, the country has steadily progressed towards a more structured and accessible model of ear and hearing care.

This transformation has been driven by national strategic planning, particularly the National Ear and Hearing Care Plan (NEHCP), alongside workforce expansion, decentralisation of services, and international collaboration.

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Workforce Expansion and Local Training One of the most striking areas of progress has been workforce development. In 1995, Rwanda had only two ENT surgeons and no audiologists or speech and language therapists.

Access to specialised ear and hearing care was extremely limited and largely centralised.

Today, there are 29 ENT surgeons in the country. Audiology and speech and language therapy have also emerged as recognised professions, with seven audiologists (with varying qualifications) and four speech and language therapists currently in practice.

A key milestone in this development has been the establishment of the ENT residency programme at the University of Rwanda, enabling local training of ENT surgeons for the first time.

Plans are also underway to establish in-country training programmes for

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audiologists and speech and language therapists, strengthening long-term workforce sustainability.

Decentralized Service Delivery ENT and audiology services have gradually shifted from a highly centralised model, previously limited to a small number of referral hospitals, towards a more decentralised system of care.

Today, selected district hospitals are able to manage basic ENT conditions, supported by community-based initiatives. This shift has significantly improved access to care, particularly for patients who previously faced long travel distances and financial barriers.

Service provision now includes basic and specialist ENT care, speech and language therapy, and audiological screening in schools, hospitals, and community settings. In addition,

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UNICEF-supported programmes have helped extend hearing aid distribution closer to communities.

The expansion of the Ear and Hearing Care (EHC) programme has further strengthened decentralised screening and management, enabling earlier identification of hearing loss at district level.

Technological Advancement and Infrastructure ENT and audiology services are resource-intensive, requiring specialised equipment that is often costly and limited in availability globally.

These challenges are compounded by competing national health priorities.

In the late 1990s, Rwanda’s ENT services were confined to only two referral hospitals, with minimal diagnostic capacity. Tympanometry, otoacoustic emissions (OAE), and auditory brainstem response (ABR) testing were

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not available, and hearing aid provision relied largely on intermittent donations.

The situation today is markedly different. National referral hospitals and an expanding private sector now have access to modern audiological equipment. Newborn hearing screening and diagnostic audiology services are increasingly available, and Rwanda has moved away from reliance on donated devices by directly procuring and dispensing digital hearing aids.

A major milestone was reached in 2025, when Rwanda performed its first cochlear implant surgeries. This represents a significant step forward in the local management of profound hearing loss and reduces the need for patients to seek care abroad.

Health Financing and Universal Coverage Although most Rwandans are enrolled in health insurance, out-of-pocket costs

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for hearing aids and assistive devices have historically remained a major barrier to access.

A significant policy development has been the inclusion of hearing aids and assistive listening devices within the benefits package of the communitybased health insurance scheme (Mutuelle de Santé). This has improved financial protection and represents an important step towards universal health coverage for ENT and audiology services.

Data, Research, and Surveillance Prior to 2000, ENT and audiology conditions were largely absent from local research and national data systems. Over the past two decades, this has changed significantly, with an increase in published clinical research and improved integration of ENT conditions into national health information systems.

Conclusion Over the past 15 years, ENT and audiology services in Rwanda have undergone substantial transformation.

Through investment in workforce development, decentralised service delivery, infrastructure expansion, and health financing reform, Rwanda has built a more resilient and accessible system of ear and hearing care.

Despite ongoing challenges, particularly in workforce distribution between urban and rural areas, continued training, decentralisation, and strategic partnerships are steadily improving equitable access to services across the country.

Conditions such as chronic suppurative otitis media (CSOM), a major cause of preventable hearing loss, are now routinely captured in national surveillance systems. This has helped improve the visibility of ENT conditions within broader health policy and planning frameworks.

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CLINICAL INNOVATION & SERVICE DEVELOPMENT

Setting up a sustainable hearing health clinic at St Francis de Sales School, Jinja, Uganda Miss Emma Stapleton Affiliations: Consultant Otologist and Cochlear Implant Surgeon, Manchester University NHS Foundation Trust; Royal College of Surgeons of Edinburgh Role: Elected Council Member, Royal College of Surgeons of Edinburgh; Editor, The Surgeon; Lead, RCSEd Mentoring Programme; Past President, North of England Otolaryngology Society; Past Chair, Women in ENT UK; Former Member, ENT UK Global Health Committee Miss Emma Stapleton is a Consultant Otologist and Cochlear Implant Surgeon in Manchester, an elected Council Member of the Royal College of Surgeons of Edinburgh and Editor of The Surgeon. She leads the RCSEd Mentoring Programme and has previously served as President of the North of England Otolaryngology Society and Chair of Women in ENT UK. Following the award of an ENT UK Global

Health Grant, Emma and colleagues have been working with local partners to develop a sustainable hearing health service at St Francis de Sales School in Jinja, Uganda. Here, she provides an update on the progress made and the lessons learned in building a locally led hearing healthcare programme.

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One of the greatest challenges in global health is ensuring that initiatives are responsible, sustainable and locally led. Projects are often judged by the number of patients seen, treatments delivered or pieces of equipment donated. However, the lasting impact of interventions in low- and middleincome countries (LMICs) depends on identifying need within the context of existing cultures and services, engaging with local colleagues as partners rather than beneficiaries, and ultimately creating services that can sustain themselves and continue to grow long after visiting clinicians have returned home.

This principle lay at the heart of an ENT UK Global Health Grant awarded to support the development of a hearing health clinic at St Francis de Sales School in Jinja, Uganda. The school provides

St Francis de Sales School, home to the hearing health clinic 34

education and support for children with hearing loss and other disabilities and serves a community where access to even basic hearing healthcare is limited by cost, accessibility and awareness. St Francis de Sales, the school's namesake, is the patron saint of deaf people.

One of the greatest challenges in hearing healthcare in low-resource settings is that children with hearing loss often do not present to healthcare services. Financial barriers, travel costs, limited specialist provision and competing family priorities can all delay assessment. As a result, many children are identified not through healthcare systems, but through education.

Teachers, parents and school staff are often the first to recognise that a child is struggling to hear, communicate or participate fully in learning.

For this reason, schools represent a valuable opportunity for hearing health interventions. They bring together children who might otherwise never access specialist assessment and provide an environment in which hearing, communication, language development and educational progress can be considered together.

St Francis de Sales School, led and run by local people and supported by Helping Uganda Schools (HUGS), is much more than a specialist educational setting. It is a vibrant community for children with hearing loss and other disabilities. Hearing and deaf children learn together, supported by teachers and staff who communicate using both spoken and sign language.

This creates an environment in which communication and inclusion are part of everyday school life. For many families, the school represents not only access to education but also access to ENT UK GLOBAL HEALTH JOURNAL 2026

Discussing hearing health with pupils at SFDS school

understanding, advocacy and support.

The vision for the project was therefore not to establish a temporary outreach clinic, but to create a sustainable local service embedded within the school itself. The aim was to equip local staff with the skills, confidence and resources needed to identify hearing problems, provide basic ear care and make appropriate referrals when specialist intervention was required.

helping to care for the next generation of children. Together, Annette and Ayesha received training in hearing assessment, otoscopy, ear care and hearing health promotion, and now lead the day-to-day delivery of the service.

A particular strength of the school is the presence of two nurses permanently based on site. Annette and Ayesha have played a central role in the development of the hearing health clinic. Ayesha’s journey is especially inspiring. Having been supported through her nursing training by HUGS, she has now returned to work at St Francis de Sales School,

What stood out throughout the programme was the remarkable enthusiasm and commitment of the staff. Training sessions rapidly evolved from demonstrations into discussions, with Annette and Ayesha eager to practise new skills and explore how they might be applied within their community. Their relationships with the children were exceptional. They understood the local challenges, knew the families personally and were deeply invested in improving outcomes for the children in their care. It became clear that the future success of the

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Ayesha and Annette learning the principles of bone conduction

clinic would depend not on visiting professionals, but on the motivation, knowledge and leadership already present within the school.

The clinic was deliberately designed around low-maintenance, sustainable equipment. The team now has access to a pure-tone audiometer with airconduction headphones and boneconduction testing capability, a rechargeable otoscope with washable speculae, audiogram recording templates and basic ear-care equipment.

These resources enable hearing screening, assessment and simple ear care to be delivered at minimal ongoing cost. The service requires little more than trained staff, cleaning materials and routine maintenance.

Importantly, the model does not depend on a continuous overseas presence.

Ongoing support is provided remotely by a UK team through WhatsApp and other online communication platforms.

Clinical questions, unusual findings and 36

practical challenges can be discussed in real time, allowing local staff to continue developing their expertise while retaining ownership of the service. This approach has proved both practical and effective. The team will continue to receive support through future visits on a biannual basis.

At present, the clinic focuses on identifying hearing loss, providing basic ear care and referring children who require further assessment or intervention. However, the local team hopes to expand its expertise gradually, establish a wider reputation for hearing health services and develop provision according to local need. The long-term ambition is for the clinic to become both a sustainable clinical service and a responsible local enterprise, generating income that can support the future development of the school and hearing service.

The development of local expertise is perhaps the most important outcome ENT UK GLOBAL HEALTH JOURNAL 2026

of the project. Sustainable healthcare cannot depend indefinitely on visiting specialists. By investing in local staff, supporting professional development and creating opportunities for trained healthcare workers to remain within their communities, the project aims to build a service capable of evolving independently. The progress made by Annette and Ayesha demonstrates what can be achieved when training, mentorship and local commitment are brought together.

hearing health among children, families and the wider population.

Perhaps the most important lesson from the project is that sustainability begins with people rather than equipment. The most valuable resource at St Francis de Sales School is not the audiometer or the otoscope, but the motivated local staff who use them. Their commitment, combined with ongoing mentorship and carefully chosen technology, provides the foundation for a service that can continue to grow and benefit local communities, while raising awareness of

Although still in its early years, this project demonstrates that sustainable hearing healthcare does not necessarily require sophisticated infrastructure or large-scale investment. With motivated local teams, appropriate training, robust partnerships and a commitment to responsible engagement, it is possible to build services that improve hearing health, educational opportunity and life chances for children whose hearing loss might otherwise remain unidentified.

Global health partnerships work best when local colleagues drive the agenda and external partners provide support rather than direction. At St Francis de Sales School, the future of the clinic will ultimately be determined by local need, local leadership and local ambition.

Our role is simply to help create the conditions in which that future can flourish.

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GLOBAL HEARING CARE & ADVOCACY

#BecauseIHearILive: Supporting deaf children across continents Smiling Crocodile’s international programme, #BecauseIHearILive, supports deaf children and those with complex disabilities across Asia and Africa through rehabilitation, training, and advocacy. In this feature, the organisation reflects on more than 15 years of global work spanning over 30 missions, highlighting the importance of holistic, community-based approaches that extend beyond hearing technology to include education, rehabilitation, and social inclusion.

Dagmar Herrmannova Affiliations: Smiling Crocodile Centre for Children with Severe Multiple Disabilities, Prague, Czech Republic Role: Founder and Director, Smiling Crocodile; Lead, International Rehabilitation and Global Outreach Programme (Asia and Africa)

For many children born with hearing loss in high-income countries, access to diagnosis, hearing technology, rehabilitation, and education is relatively well established. However, in many low- and middle-income countries, thousands of deaf children still grow up without timely access to hearing care.

Barriers including poverty, geographic isolation, limited specialist services, ENT UK GLOBAL HEALTH JOURNAL 2026

and lack of awareness continue to delay diagnosis and intervention, often with lifelong consequences for communication, education, and social inclusion.

This global disparity in access to care is the focus of the international work of Smiling Crocodile (www. smilingcrocodile.org).

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Originally established in the Czech Republic as a centre for children with severe multiple disabilities and a developing children’s hospice in Prague, Smiling Crocodile has expanded its scope since 2009 to include international programmes across Asia and Africa. Its work focuses particularly on children with hearing loss and complex disabilities living in underserved and resource-limited settings.

The overarching aim is to improve access to hearing, communication, rehabilitation, education, and social inclusion for children who might otherwise be excluded from care pathways.

Children with hearing loss require a broader ecosystem of support, including rehabilitation therapy, family engagement, access to education, transport, trained professionals, and social acceptance.

Over the past 15 years, Smiling Crocodile has supported more than 3,000 children through its international missions and the awareness campaign #BecauseIHearILive, launched in 2016.

The initiative integrates rehabilitation services, professional training, awareness activities, documentary filmmaking, music projects, and humanitarian field missions.

A defining feature of the programme is its recognition that hearing technology alone is not sufficient to ensure meaningful outcomes.

International activities are led in part

by Dagmar Herrmannova, whose long-term engagement has connected rehabilitation centres, hospitals, therapists, and families across multiple continents. Her work has focused on strengthening local capacity through training, while also ensuring that children receive access not only to hearing technology, but also to long-

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A holistic approach to hearing loss

term rehabilitation and communication development.

Reaching children in underserved settings To date, Smiling Crocodile has conducted more than 30 international missions in countries including India, Bangladesh, Nepal, Sri Lanka, Malawi, Kenya, Tanzania, Ghana, Ethiopia, Côte d’Ivoire, Zimbabwe, Russia, and Kazakhstan.

These missions often take place in highly challenging environments, reaching children in rural communities, urban settlements, schools, hospitals, and rehabilitation centres. In many cases, families travel long distances to attend a single therapy session, reflecting the scarcity of services and the financial burden of accessing care.

Beyond clinical support, the organisation provides therapeutic tools, supports rehabilitation centres, and delivers training for local professionals working with children with hearing loss and ENT UK GLOBAL HEALTH JOURNAL 2026

complex disabilities. A key component of this approach is sustainability, with emphasis on equipping local teams to continue care beyond visiting missions.

Practical innovations have also emerged from this work. In one example, a tuktuk transport system was introduced to enable children living in underserved communities to attend rehabilitation sessions regularly, demonstrating how small logistical interventions can have a significant impact on continuity of care.

In Nepal, Smiling Crocodile contributed to the renovation of hospital facilities to strengthen rehabilitation services. In Bangladesh, it has supported children balancing schooling with work, helping improve access to education and rehabilitation in highly constrained socioeconomic contexts.

Innovation, education, and awareness Alongside field-based rehabilitation work, Smiling Crocodile has developed the Listen with Smile app, designed to support auditory training and listening 41

development through accessible, childfriendly tools.

A central pillar of the programme is advocacy and awareness. The #BecauseIHearILive campaign has become an international platform bringing together deaf children, families, clinicians, therapists, and artists to promote inclusion and visibility.

In collaboration with Czech singer Milan Peroutka and artists across Asia and Africa, the organisation has produced multiple versions of the campaign’s anthem, featuring children with cochlear implants performing alongside professional musicians. These creative collaborations aim to challenge stigma while highlighting the potential of children with hearing loss when given appropriate support.

In parallel, a series of documentary films has captured the lived experiences of deaf children and adults across diverse cultural and healthcare settings, 42

illustrating both the challenges and the resilience of families navigating hearing loss in low-resource environments.

Partnerships and global collaboration The programme has also benefited from collaboration with MED-EL and the support of Dr. Ingeborg Hochmair, contributing to training, awareness, and cochlear implant rehabilitation initiatives in underserved regions.

These partnerships have supported capacity-building and improved access to specialised hearing care in multiple countries.

Smiling Crocodile’s work has been featured in international media outlets including The Times of India, The Hindu, The Daily Star, and ENT & Audiology News, reflecting its expanding global engagement.

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Challenges and resilience Despite its achievements, the programme has faced significant challenges. Field teams have worked through extreme weather events, political instability, logistical constraints, and at times security-related incidents during missions. These experiences highlight the complexity of delivering consistent rehabilitation services across diverse and often unpredictable environments.

However, they have also strengthened collaboration, resilience, and shared commitment among local and international teams.

Conclusion At its core, Smiling Crocodile’s work highlights a fundamental principle of global hearing health: hearing loss is not only a medical condition, but also a social, educational, and developmental challenge.

For children who have never heard a voice, a song, or their parent calling their name, access to hearing care can be transformative. Yet meaningful impact requires more than technology alone; it requires rehabilitation, education, family support, and inclusion within society.

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FREE PAPER PRIZE WINNERS – BACO 2026

WINNER Jonathan Abaho Abstract Title Scaling Rural ENT Access and Training Through a District-Level Clinic in Rwanda: A Model for Decentralized Specialty Care

Study Background and Aims

Results

ENT services remain limited in rural subSaharan Africa. In 2024, a district-level ENT clinic was established in Butaro, Northern Rwanda, through collaboration between UGHE, ROHNNS, and the Rick Godley Foundation. The initiative aimed to improve access to ENT care while integrating structured clinical training for medical students in a rural setting.

Over 350 patients were assessed, most commonly for foreign bodies, allergic rhinitis, and otitis media. Students reported increased clinical confidence and interest in ENT. Local staff received structured mentorship, and essential ENT instruments were procured. The programme supported integration of ENT teaching into the rural medical curriculum.

Methods

Discussion and Importance to the Field

Patient visit logs, procedural records, diagnostic trends, and student logbooks were reviewed from January 2024 to June 2025. Student feedback was collected using reflective forms and qualitative surveys. Capacity-building activities and equipment upgrades were documented. Descriptive and thematic analysis was used to evaluate service delivery and educational impact.

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This model demonstrates how districtlevel ENT services can improve access while strengthening decentralized clinical education. Strategic partnerships enabled workforce development and sustainable service delivery. The project provides a replicable framework for integrating specialty care and training within under-resourced health systems in LMIC settings.

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RUNNER-UP Isobel Marks Abstract Title Establishing Sustainable Ear and Hearing Healthcare Provision for Rohingya Refugees in Bangladesh

Study Background and Aims

Results

Hearing loss affects over 1.5 billion people globally, with limited access to care, particularly in refugee settings. In Rohingya camps in Bangladesh, poor infrastructure and limited investment exacerbate unmet ear and hearing healthcare needs. This project aimed to assess services and strengthen primary ear and hearing care delivery.

Thirty-one managers and 45 clinicians participated. Ninety-three percent managed ENT conditions daily, with otorrhoea most common. While 81% used otoscopes, only 6% had access to microsuction. Key barriers included limited training, lack of referral pathways, and insufficient equipment.

After training, 32 clinicians completed the course and 97% reported improved confidence in practice.

Methods A needs assessment was conducted in Rohingya refugee camps assessing ENT service provision at primary care level.

NGO managers and clinicians were surveyed. A two-day training course based on WHO Primary Ear and Hearing Care guidelines included otoscopy, ear care, history taking, and practical skills stations, delivered alongside targeted lectures.

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Discussion and Importance to the Field This project strengthened primary ear and hearing care in a refugee setting without onsite ENT specialists. A structured needs assessment informed targeted skills training for frontline health workers. Future work will focus on improving referral pathways and developing access to surgical care for chronic ear disease in this population.

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ACKNOWLEDGEMENTS

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1-3 July 2026 - SEC Glasgow