Orginal Article

International Journal of Audiology 2006; 45:262
266

De Wet Swanepoel Audiology in South Africa

Department of Communication
Pathology, University of Pretoria,
South Africa
Audiologı́a en Sudáfrica

Key Words Abstract Sumario

Audiology Audiology in South Africa is an established profession
South Africa facing the challenge of serving a diverse population in
predominantly developing contexts. The profession has
Developing country developed over the last half century from an adjunct to
Hearing loss speech-language pathology into a profession in its own
HIV right. Several tertiary institutions offer undergraduate
training in audiology with optional postgraduate quali-
fications. Institutions are continually adapting to a
profession characterised by rapid change
evidenced
even in the very composition of the profession itself. This
article aims to provide an overview of the development
and current status of audiology as a profession in South
Africa.
La Audiologı́a en Sudáfrica es una profesión establecida
que enfrenta el desafı́o de servir a una población muy
variada en contextos predominantemente en desarrollo.
La profesión se ha desarrollado en el último medio
siglo como complemento de la patologı́a del habla/
lenguaje hasta convertirse en una profesión por su propio
derecho. Algunas instituciones del tercer nivel ofrecen
entrenamiento de pregrado en Audiologı́a con opciones
de calificaciones de posgrado. Las instituciones
están continuamente adaptándose en una profesión
caracterizada por sus rápidos cambios que se hacen
evidentes incluso en la variada composición de la
profesión en si misma. Este artı́culo tiene como objetivo
proporcionar una visión del desarrollo y el estado actual
de la Audiologı́a como profesión, en Sudáfrica.

2003). It is within this multiracial, multilingual, and multi-

cultural context that the field of audiology in South Africa has
emerged over the second half of the previous century as a
hearing healthcare profession aimed at providing quality services
to meet the diverse needs of the entire population.

History of audiology
Audiology in South Africa evolved over the course of the past
five decades from an adjunct to the profession of speech-

in South Africa



Professor P. de V Pienaar (1904 1978) Founder of the profession
Audiology in South Africa is a growing profession facing the
challenge of providing services to the hearing-impaired of a
diverse country at the tip of the African continent. South Africa
has been described as the ‘rainbow nation’, not only because the
country has four or five relatively different climates and a vastly
contrasting geography, but primarily for its diverse collection of
peoples and cultures (Tuomi, 1994). The population is hetero-
geneous with mixed sections of developed and developing
contexts that are classified collectively as a developing nation.
The estimated population size in 2002 was 45.1 million
compared to 40.6 million for the 1996 census (Statistics South
Africa, 2003). The population comprises various race groups
presented in Figure 1.
The racial diversity of the country is further diversified by
various cultures within races, each with its own language or
dialect. This is evident in the recognition of eleven official
languages for South Africa of which English is only the fifth
most commonly spoken language (8%) (Statistics South Africa,
language pathology into an autonomous profession in its own
right. Both of these professions were introduced to South Africa
by the late Professor Pierre de Villiers Pienaar, who after
completing his doctoral studies at the University of Hamburg,
Germany, returned to South Africa to institute a professional
qualification for speech-language therapists. The first pro-
gramme was established in 1938, at the University of the
Witwatersrand, Johannesburg, and trained therapists over two
years for a diploma in logopaedics. Realising that the breadth of
the field required more intensive training, the diploma quickly
stretched to three years and subsequently changed to a four-year
professional degree course in 1948. Professor Pienaar initiated
the second tertiary training programme at the University of
Pretoria in 1959, but it was not until 1962, that the field of
audiology was formally introduced as a two-year major in the
four-year curriculum at both universities (Aron, 1973).
The emergence of speech-language therapists and audiologists
qualified with a four-year university degree, along with the
relentless efforts by Professor Pienaar to establish positions
within the public education and healthcare sector for therapists
and audiologists, led to the foundational establishment of the

ISSN 1499-2027 print/ISSN 1708-8186 online Accepted: De Wet Swanepoel

DOI: 10.1080/14992020500485650 October 24, 2005 Department of Communication Pathology, University of Pretoria, Pretoria, 0002
# 2006 British Society of Audiology, International South Africa.
Society of Audiology, and Nordic Audiological Society E-mail: dewet.swanepoel@up.ac.za
 8.9%
2.5% Black African
9.6% White
Indian or Asian
Coloured
79%
Figure 1. Distribution of South African population according
to race (Statistics South Africa, 2003).
profession in the public and private contexts. As awareness of
the services offered by this new profession increased, the need for
audiologists and speech-language therapists also increased,
resulting in the initiation of new training programmes at several
universities countrywide.
Training in audiology
Education for audiologists in South Africa has always been
closely related with speech-language pathology. Since 1948,
training has been in the form of a four-year bachelor’s degree,
equivalent to an honours degree, which qualifies a student as
both a speech-language therapist and an audiologist. A second-
ary education level of Grade 12 is required to enrol for the
course, but applications far exceed the training capacity making
selection of only the top candidates necessary. Training institu-
tions are enrolling student groups that are increasingly repre-
sentative of the ethnic, linguistic, and cultural diversity of South
Africa to redress a historically white Afrikaans- and English-
speaking profession. There are currently five universities offering
training in audiology. Table 1 provides the names of the
institutions, the degree description and the approximate number
of students graduating annually. Students may also enrol for
postgraduate degrees, including master and doctoral degrees.
At the turn of the 20th century, some training institutions
began to offer a choice of qualifying in either speech-language
Table 1. Institutions offering training in audiology
Institution
University of Pretoria, Department of
Communication Pathology
University of the Witwatersrand, Discipline
of Speech Pathology and Audiology
University of Cape Town, Division of
Communication Sciences & Disorders
University of KwaZulu-Natal, Audiology and Speech
and Language Department
Medical University of South Africa (MEDUNSA),
Speech, Language Pathology and Audiology Department
*Averaged estimates.
Audiology in South Africa
pathology or audiology. Currently this process is in a transitional
phase with some institutions having separated the training
without an option to qualify in both whilst other institutions
still offer a combined qualification. This move toward a clear
distinction between the professions has come about as a result of
international trends and the increasing demands of providing
adequate standards of training in two rapidly expanding
professions. Despite these pressures there has been a resistance
toward the total separation of the qualifications from certain
stakeholders. This is attributed to the fact that South Africa is a
developing country with a primary healthcare system that relies
heavily on professionals being generalists (i.e. qualified in both
audiology and speech-language pathology) who can attend to a
variety of communicative disorders. The public healthcare
system, therefore, favours appointments of professionals with a
combined qualification in speech-language pathology and
audiology instead of those qualified in one or the other. In the
private sector, however, the professions are almost exclusively
practised separately due to the fact that specialised services in
either require a dedicated pursuit in that field of practice.
Currently, there is no difference in scope of audiological practice
whether dually qualified as audiologist and speech-language
therapist or as audiologist only.
Registration as a professional audiologist with the Health
Professions Council of South Africa is based on completion of a
four-year degree in audiology at one of the five tertiary
institutions and a subsequent year of community service whether
qualifying in both speech-language pathology and audiology or
only in one of these. The community service year was instituted
in 2003 and requires new graduates to serve in the national
healthcare system for one year (Padarath et al, 2004). This
means graduates have an additional year of inservice training
before they are licensed to practice the profession of audiology.
Annual registration with the Health Professions Council of
South Africa and accumulation of Continued Professional
Development (CPD) hours are mandated for professional
practice. There are also professional bodies to which audiologists
may belong, including the South African Speech Hearing and
Language Association (SASHLA) and the South African
Academy of Audiology (SAAA).
Graduates
Degree Name Annually*
B. Communication Pathology (Speech- 40
Language Therapy and Audiology)
B. Communication Pathology (Audiology)
B.A (Speech and Hearing Therapy) 30
35
BSc. Audiology 11
B. Communication Pathology (Audiology) 12
B. Speech Language Pathology and 8
Audiology (BSLP&A)
Swanepoel 263
 Over the years a number of related qualifications apart form
audiology have emerged to address the communication needs in
communities. One such qualification was a year diploma for
teachers of speech-defective and partially hearing pupils instituted
in the 1930’s at the University of Cape Town which was
discontinued in 1984. Recipients of this qualification were
registered with the Health Professions Council of South Africa
as speech and hearing correctionists (Aron, 1991). Another related
qualification was an undergraduate two-year diploma instituted at
the University of the Witwatersrand in 1984, for community
speech and hearing workers. This diploma was an attempt to
address the basic speech and hearing needs of rural South African
communities but was subsequently discontinued (Aron, 1991). An
additional affiliated profession registered with the Health Profes-
sions Council of South Africa is that of hearing aid acoustician.
At the turn of the century, the qualification became a formalised
two-year postgraduate diploma at the University of Pretoria in an
effort to ensure quality control of a profession that was poorly
regulated historically. The scope of practice for hearing aid
acousticians excludes professional functions of the audiologist
such as services to children younger than twelve years of age.
Human resources in audiology
Approximately 2461 speech-language therapist audiologists are
registered with the Health Professions Council of South Africa
(HPCSA, 2005). Since speech-language pathology and audiol-
ogy traditionally constituted a combined qualification offered by
South African universities, registration with the Health Profes-
sions Council of South Africa was as both speech-language
therapists and audiologists. The recent changes in university
courses have allowed qualification as either a therapist or
audiologist, or both. Since this change, 88 audiologists have
been registered with the council (HPCSA, 2005).
In terms of the population size and the number of qualified
audiologists, there is an obvious shortage of manpower in the
public health sector of South Africa (Uys, 1993). Based on the
international estimated prevalence of congenital hearing loss of
2.2%, there must be approximately one million individuals with
hearing loss in South Africa (Mencher, 2000). If a South African
prevalence estimate of 10% is used (Sellars & Beighton,
1997), the number of individuals with sensorineural hearing
loss is approximately 4.5 million. According to these prevalence
estimates, if only half of the registered audiologists /speech-
language therapists in South Africa provide dedicated audio-
logical services, each of these audiologists are required to serve
between 900 and 4 000 individuals with permanent hearing loss.
However, the majority of these audiologists are in private
practice and provide services to a small minority in the country
only
primarily to people from developed contexts who can
afford these services. The largest majority of the population with
a higher prevalence of congenital hearing loss due to socio-
economic deprivation (Kubba et al, 2004) cannot afford audio-
logical services in private practice and rely on the national
healthcare system. This significantly increases the ratio of
individuals with hearing loss per audiologist in the national
healthcare system, which serves the largest proportion of the
population. This problem is exacerbated by the fact that many of
the national healthcare positions for audiologists and speech-
language therapists are filled by community speech and hearing
264
workers who are not adequately trained and qualified to deliver
audiological services (Doctoroff, 1995). Previously, audiologists
preferred not take up these positions because of a more lucrative
market in the private sector. It is therefore clear that there are an
overwhelming number of individuals with hearing loss, specifi-
cally in the public healthcare sector, who require audiological
services from a very small number of adequately qualified
professionals.
Audiological services
A competency document accepted by the Professional Board for
Speech Language and Hearing Professions of the Health
Professions Council of South Africa in 2003, describes the
profession of audiology in South Africa as a healthcare and
educational profession which is primarily concerned with service
delivery in the form of prevention, identification, evaluation,
diagnostic treatment, and intervention for individuals with the
following impairments:

‘organic pathology of the peripheral and central hearing and
balance system;

functional hearing loss;

central auditory processing disorders;

developmental or acquired language and language processing
impairments affecting phonology, morphology, syntax, se-
mantics and pragmatics as it relates to the oral, written, and
graphical modalities including sign language and other
nonverbal communication systems which occur as a result
of a hearing loss (these language impairments include
impairments of the aspects which are foundational to
language and language development, namely the cognitive,
emotional, and social aspects of a person);

developmental or acquired speech impairments which are the
result of a hearing loss with specific reference to articulation,
phonological, and voice disorders (including respiration,
phonation, prosody and resonance).
(Hugo, 2004)
During the past fifteen years large-scale changes have occurred
in the South African sociopolitical arena. These developments
have not only been political but have also brought about changes
in national health, education, and welfare policy. An ongoing
paradigm shift in the professions of audiology and speech-
language pathology in South Africa has mirrored these political
changes in order to improve imbalanced service delivery, redress
teaching programmes, and focus its research endeavours on the
specific needs of the context. The use of traditional institution-
based models of service delivery in the field of audiology and
speech-language pathology has proved to be ineffective in
reaching the majority of vulnerable and disadvantaged commu-
nities in South Africa (Moodley et al, 2000). The resultant
transformation, therefore, has been towards a community-based
service delivery model for audiological and speech-language
pathology services to meet the unique needs of the broader
South African community (Uys & Hugo, 1997). For audiology
in South Africa, this implies a delicate balance between the
specialised technologically dependent services, which are invari-
ably institution-based, and a more general preventative ap-
proach providing basic hearing healthcare services within
communities.
International Journal of Audiology, Volume 45 Number 5
 Audiological services are provided in a variety of settings
including public healthcare facilities such as provincial or
regional hospitals, in schools for children with special needs, in
private practices, and also at universities. The scope of practice
includes basic and advanced audiometric procedures, electro-
physiological tests of auditory and vestibular functioning,
hearing aid selection fitting and minor repair, counselling, and
provision of intervention or rehabilitation programmes. Unfor-
tunately cerumen management has not yet been included in the
audiological scope of practice to the detriment of primary
healthcare delivery by audiologists. Currently very few newborn
hearing screening programmes are operational, apart from a
number of pilot programmes at public healthcare institutions
and in private hospitals where newborns are screened on request
from the parents (Swanepoel et al, 2004). In 2002, the HPCSA
produced a hearing screening position statement for infants
which was largely based on the Joint Committee of Infant
Hearing Year 2000 position statement (HPCSA, 2002). The
South African position statement is currently under revision in
light of initial data from pilot studies which indicate that
reconsideration of first-world models are necessary for infant
hearing screening in South Africa to be viable (Swanepoel et al,
in press).
Rehabilitative services for hearing loss are provided through
basic analogue hearing aids supplied by the public healthcare
system at minimal administrative costs to the patients. Unfortu-
nately there are often long waiting lists with preference given to
infants and young children (Wansbury, 2002). Hearing aids are
also dispensed by audiologists in the private sector, in which case
the patient is responsible for the full payment of the device,
although membership of a private medical scheme often con-
tributes a significant amount to the final payment. Unlike
hearing aids, cochlear implants are not available through the
public healthcare system and it is only recently that private
medical aids have begun to contribute towards the device and
surgical procedure. There are several programmes conducting
cochlear implants in South Africa. The first team to perform
implantations started in 1986 and the national number of
implants steadily increased to approximately 50 annual implants
in 2003, and 77 annual implants in 2004, of which 17 were
bilateral. The growth in annual implantation evidences the rapid
development of audiology in South Africa in following interna-
tional trends.
Challenges to audiology
Pienaar, the father of speech-language pathology and audiology
in South Africa, wrote as early as 1962, ‘[a] young country, with
a comparatively small percentage of wage earners, keen on
expansion in every sphere of life, with no endowments and
handicapped by a lack of funds, has had to march forward on
faith, hope, and charity and its youthful idealism. We are jealous
of our standards of training, of research and therapeutics . . . We
realise the vastness of the field still lying fallow; the great task
still ahead of us to cater to the needs of the whole population of
South Africa and through South Africa to the whole of the
awakening Southern Africa’ (Pienaar, 1962 in Cilliers, 1980:1).
Over forty years later, with a new government and new
healthcare system, the main aim of audiology in South Africa
Audiology in South Africa
has remained the same
availability of accountable services to
all peoples.
Major challenges to the provision of adequate audiological
services to the majority of the population can be attributed to an
insufficient number of audiologists unequally distributed be-
tween the private and public sector, and a culturally and
linguistically underrepresented profession. The number of qua-
lified audiologists is inadequate to meet the demand for services,
and the vast majority of these professionals enter the private
sector, nationally and internationally, for a more lucrative career.
Delivering services that are linguistic and culturally appropriate
to the vast majority of the population is also a significant
challenge to the audiological community in South Africa. The
multilingual and multicultural characteristics of South Africa,
where the minority of people are mother tongue speakers of
English and Afrikaans, is a considerable barrier to a profession
with only a small percentage of professionals who speak an
African language (Uys & Hugo, 1997).
The overwhelming burden of infectious disease, especially
HIV/Aids, is another unique challenge to audiological service
delivery in South Africa. At the end of 2002, South Africa
presented with an estimated 5.3 million HIV cases
the highest
of any country in the world (UNAIDS, 2003). An estimated HIV
prevalence rate of 26.5% was reported among sexually active
women aged between 15 and 49, and surveys by the Department
of Health indicate an estimated HIV prevalence rate of 11.4%
across the general population (Department of Health, 2002).
This situation leads to health priorities that are aimed at saving
lives rather than at improving quality of life and neglects an
invisible non-life-threatening condition such as hearing loss.
Although hearing loss is indeed not a life-threatening condition,
it becomes a severe threat to essential quality of life indicators
unless intervention occurs early during infant development. The
adverse effects of hearing loss on cognitive-linguistic skills and
psychosocial behaviour are well established in contrast to the
established benefits of early intervention (Moeller, 2000; Yoshi-
naga-Itano, 2003).
Cultural differences in perception of disabilities may also
result in inaction, since a characteristic of African families, for
example, is often a fatalistic outlook that leads to a passive,
accepting attitude toward hearing loss (Louw & Avenant, 2002).
These factors make it difficult to attract resources towards the
effective management of hearing loss in infants. Even when
resources become available, ongoing commitment to prevention
programmes is uncertain because the consequences of inaction
may not seem as frightening as in other epidemics (Olusanya,
2001).
Another persistent challenge to the profession of audiology is
the severe dearth of contextual data regarding the prevalence
and etiology of hearing loss and the status of hearing healthcare
in South Africa. Although a number of small-scale studies have
been performed, there has been no large-scale study to establish
accurate prevalence data for childhood hearing loss or to
determine the status of services for the hearing-impaired in
South Africa. These research results are necessary to gain
legislative support in favour of the hearing-impaired of South
Africa and to initiate large-scale infant hearing screening
programmes (Swanepoel et al, 2004). Initiatives of this kind
are necessary to prioritise incorporation of disability and quality
Swanepoel 265
of life issues associated with hearing loss on the national
healthcare agenda.
The future of audiology
The professions of audiology and speech-language pathology in
South Africa are transitioning into two separate autonomous
professions in tertiary education. This shift in training, along
with the Health Professions Council of South Africa’s recogni-
tion and encouragement of audiology as an autonomous
profession in South Africa, now demand that rigorous standards
of competencies are clearly specified and upheld by training
institutions and the Professional Board. Although international
standards of competencies provide useful guidelines, it is
essential that the training emphasis be rooted in the nature of
the specific communities to be served in South Africa. The past
50 years have laid a firm foundation for the profession of
audiology in South Africa. Sociopolitical changes have come
and gone, but the challenge for the profession has remained the
same-to provide accountable services to the entire population
based on quality training and contextual research efforts.
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