Global and National Situation of Ear and Hearing Care (EHC)

Global and National Situation of Ear and Hearing Care (EHC)

WHO highlighted in the World Hearing Report 2021, that globally more than 1.5 billion people experience some degree of hearing loss. Of these, an estimated 430 million have hearing loss of moderate or higher severity in the better hearing ear, most people affected live in low- and middle-income countries of the world. If unaddressed, hearing loss can negatively impact many aspects of life: communication; the development of language and speech in children; cognition; education; employment; mental health; and interpersonal relationships. Hearing loss can cause low self-esteem, is often associated with stigma, and can significantly impact the families and communication partners of those living with the condition.

The World Hearing Report is divided into four major sections.

Importance of hearing across the life course – An individual’s hearing trajectory depends on the baseline capacity at birth, and the multiple risk or preventive factors encountered during the life course. Genetic and intrauterine factors affect pre-natal period, birth asphyxia and LBW are the factors that affects peri-natal stage, childhood and early adolescent factors include Otitis Media and Meningitis, chronic diseases, otosclerosis, age related sensory neural degenerations affect adolescent and old age while some factors affect across the life span including cerumen impaction, trauma to ear or head, noise/loud sounds, ototoxic medicines and chemicals, nutritional deficiencies, viral infections and other ear conditions. 

Solutions across the life course: hearing loss can be addressed – Many of the causes that lead to hearing loss can be avoided through public health strategies and clinical interventions implemented across the life course. Prevention of hearing loss is essential throughout the life course – from prenatal and perinatal periods to older age. Effective strategies for reducing hearing loss at different stages of the life course include:

• Immunization
  • Good maternal and childcare practices
  • Genetic counselling
  • Identification and management of common ear conditions
  • Occupational hearing conservation programmes for noise and chemical exposure
  • Safe listening strategies for the reduction of exposure to loud sounds in recreational settings
  • Rational use of medicines to prevent ototoxic hearing loss.

Challenges facing ear and hearing care – Key challenges facing the field of ear and hearing care (EHC) are grouped into three categories.

1. Demographic and population trends.
2. EHC literacy, and stigma associated with hearing loss.
3. Health system related issues.

Demographic and population trends reflect the high, and rising, global prevalence of hearing loss. By 2050, it is estimated that some 2.5 billion (1 in every 4) people will experience hearing loss, with nearly 700 million (1 in every 14) living with moderate or higher levels of hearing loss in the better hearing ear.

Designing the way forward: A public health framework for ear and hearing care – Universal health coverage (UHC) is the key to achieving Goal 3 of the Sustainable Development Goals (SDG3) by 2030.

Access to ear and hearing services is summarized in the term “Ear and hearing care”, which refers to a broad range of services for health promotion, prevention, identification, management, and rehabilitation, delivered through national health systems.

The scope of ear and hearing care extends beyond health systems, covering access to education and communication as well as other support required for persons with hearing loss and their families. This is achieved through multisectoral collaborative action, in line with the principles of integrated people-centred ear and hearing care (IPC-EHC).

Key public health interventions for EHC provision across the life course are summarized in the acronym “H.E.A.R.I.N.G.”:

• Hearing screening and intervention
• Ear disease prevention and management
• Access to technologies
• Rehabilitation services
• Improved communication
• Noise reduction
• Greater community engagement

The provision of IPC-EHC services requires action at all levels of the health system through:

Leadership and governance, for ensuring equitable access to EHC services at all levels of health-care service provision through policy guidance and planning; collaboration and coalition-building across sectors; regulations including their enforcement; and oversight.

Sustainable financing and social protection, so that people can access quality EHC services.

A competent, motivated, and empowered health workforce, which is essential for the effective provision of quality EHC services.

Robust health information systems that support IPC-EHC and help to determine population needs and priorities; identify gaps in health systems’ capacity; and report progress.

Equitable access to essential medical products and technologies of assured quality, safety, efficacy, and cost–effectiveness through inclusion in government lists of EHC-related diagnostic equipment, medicines, surgical equipment (for ear surgeries), hearing technologies and relevant vaccines.

Governments and partners should also focus on relevant and impact-oriented research that supports implementation of IPC-EHC across the life course.

Situation of Ear and Hearing Care in Pakistan

Burden of Disease – The world report on disability 2011 shows a 13.4% of estimated disability in Pakistan. The Pakistan Bureau of Statistics revealed in district level Pakistan Social and Living Standards Measurement (PSLM) survey  there are more than 37.0 million persons with disabilities in Pakistan. Using the estimates from World Report on Hearing, persons with disabling hearing loss are approximately 4.45 million, of which 1 million are children of school age and  only 5% attend special school.

Pakistan Poverty Alleviation Fund (PPAF), a social sector and development national organization, conducted a survey in 2010 shows 12% disability and prevalence of hearing disability is 2% – which is made up of mild-moderate disability of 1.7% and severe disability of 0.3%.

Rapid Assistive Technology Assessment (rATA) baseline survey, was conducted by Ministry of Health Services, Regulations and Coordination (MoNHSRC) and supported by WHO and Health Services Academy (HAS), launched on 3^rd December 2021. rATA was conducted in 16 districts and a sample of 64,000 was covered. It stated 4.8% sample have “difficulty with hearing” and identified “a substantial un-met need for hearing aids with batteries as assistive product”.

• 3.3% sample have “some difficulty”.
  • 1.1% sample have “a lot of difficulty”.
  • 0.4% sample “cannot do at all” (total 4.8%)
  • 3.1% sample have “some difficulty” with speaking/communication.

The report recommended to improve access to assistive products for everyone, everywhere – leaving no one behind.

Some school screening surveys show almost 33% children have mild to moderate hearing impairment, mostly due to impacted wax and compromised personal hygiene. Repeated infections, discharging ears and perforated ear drum were also observed.

Medical Products and Technology – There is no evidence of a standard list of infrastructure, equipment or medicines and consumables for ENT departments. It is revealed that a variety of hearing aids and its accessories are available in Pakistan, and there is some support from the government to provide these through Bait-ul-Mal, the delivery time may take several months. Audiology tests are also widely available, at no cost in the government hospitals and on payment in the private sector. Cochlear implants are available but are costly. Speech therapy services exist but are limited. Screening new-borns for hearing has been initiated in some tertiary hospitals.

Health Information – The Lady Health Worker programme, which includes a workforce of more than 100,000 who are the building block of the primary health care system at community level, does not have any indicator for reporting on ear and hearing health.

Health Financing – Government health financing for ENT services is currently merged under General Hospitals and Clinics in the health budget and there is no dedicated allocation for ear and hearing care.

Leadership and Governance – There is at present no national or provincial governance structure for an ear and hearing health programme, nor is there any national or provincial ear and hearing health programme.

Special Education – More than 600 organizations working for the welfare of persons with disabilities, both in the government and private sectors. Of these, at least 100 organizations are working for deaf and hearing impairment.

Summary Recommendations –

1. The Ministry of National Health Services, Regulations and Coordination, is urged to set up and notify a national committee for ear and hearing health to provide strategic direction, and for Provincial Health Departments to notify appropriate provincial committees on ear and hearing health to develop, coordinate, implement and monitor provincial ear and hearing health plans.
2. Primary ear and hearing health should be integrated within primary health care programmes.
3. There is need to develop a standard list of infrastructure, equipment and medicines and consumables for ENT departments.
4. Capacity building and integration in existing health programmes (where feasible) is required for screening new-borns for hearing impairment and deafness. Screening for hearing impairment be included be included in the school health programmes.
5. Further data is required about the degree of hearing loss, type and frequency of ear and hearing disorders, and their causes.
6. There is need to conduct an ENT health workforce survey to determine the types of cadres, their deployment and distribution among the government, private and NGO sectors.