Hearing loss affects more than 1.5bn people worldwide, about 80% of them in low- and middle-income countries, where hearing care is out of reach for most. In Africa, around 136 million people have hearing loss, a figure expected to more than double to 337m by 2050, yet fewer than 2% of people here who need a hearing aid have one, writes De Wet Swanepoel in The Conversation.
But solutions are available – and attainable – with some political will, among other investments.
Swanepoel writes:
This shortfall is not a minor inconvenience but a major public health crisis. Left unaddressed, hearing loss drives costs across healthcare, education and productivity, falling hardest on children, whose language development and schooling depend on being able to hear.
A 2024 Lancet Commission report identified it as one of the largest modifiable risk factors for dementia. The World Health Organisation puts the annual global cost of unaddressed hearing loss at close to a trillion US dollars (page 10).
Despite this, access to care remains scarce. There are too few audiologists (fewer than one for every million people in many African countries), hearing aids cost more than a year’s income for many households, services are concentrated in cities and a persistent stigma keeps people from seeking help even where it exists.
Our research team at the University of Pretoria, where I head the WHO Collaborating Centre for the Prevention of Deafness and Hearing Loss – the only such centre on the continent – has spent the past decade pioneering ways to close this gap.
Our latest study reviews a decade of evidence on whether hearing care can be delivered outside clinics, by people who aren’t specialists.
Our data show that the pieces are now in place. Affordable devices, automated mobile testing tools and non-specialist training have each been shown to work. Together they form a care pathway that can deliver hearing services to most adults with hearing loss outside clinics, meeting people where they are.
Rethinking who provides frontline community care
The traditional model for fitting a hearing aid has barely changed in decades: a patient visits an audiologist, undergoes testing in a soundproof booth, and returns for several follow-up appointments. That works reasonably well where specialists are plentiful. It cannot scale in places where the nearest audiologist is hours away.
What our work shows is that this no longer has to be the only way. Over the past several years, our research group and others have been testing a “high-tech, soft-touch” approach: training community health workers – trusted, non-specialist members of the community – to carry out the essential steps of hearing care themselves, using smartphones and tablets loaded with validated apps.
This is already happening in three low-income communities in South Africa: Khayelitsha and Mbekweni in the Western Cape, and Atteridgeville in Gauteng.
The process typically runs through five steps: a tablet or smartphone hearing test; an ear examination using a small camera attached to the phone; a chance to try a hearing aid; fitting of an affordable, rechargeable device; and several weeks of support delivered by text message or WhatsApp. A remote audiologist checks the results without ever needing to be in the room.
In several of our South African studies, a single visit was enough for a person to walk away wearing a hearing aid fitted to their own hearing loss.
Much of this evidence comes from work with the hearX Foundation, the non-profit implementation partner of our research centre. Led by audiologist Tersia de Kock, the foundation trains and manages the community health workers.
Does it actually work?
Community health workers have now fitted hearing aids for hundreds of adults across South Africa, and outcomes – hearing aid use, satisfaction, quality of life – are broadly comparable to traditional clinic-based care.
In several of our studies, we found that more than 70% of people were still using their devices six months on, a retention rate that compares favourably with many specialist-led programmes in high-income countries.
Two developments have made this possible. The first is the emergence, largely over the past decade, of affordable digital technologies for ear and hearing assessment that rely on automated testing that can be facilitated by community health workers with minimal training.
The second is low-cost preset hearing aids that don’t need individual programming by an audiologist and that increasingly use rechargeable batteries. This removes one of the most underestimated barriers to hearing aid use in poorer communities: reliable access to disposable batteries.
None of this means the model is perfect. Most evidence so far comes from small studies run by research teams, not from health systems delivering this care routinely at scale.
Brazil and India offer a glimpse of what that could look like: both have built hearing care into their national public health systems at scale. We also don’t yet know enough about long-term outcomes when people select their own hearing aid programme rather than having one fitted to clinical hearing test results, called an audiogram.
And stigma remains a barrier that technology alone won’t solve. Some people see hearing aids as a sign of old age, and sometimes cultural beliefs link hearing loss to misfortune.
Our recent review of stigma in low- and middle-income countries found that generic awareness campaigns developed for wealthier countries made little difference. What does work is education delivered by trusted local figures (community leaders, religious institutions, peer networks) and grounded in local beliefs and language.
What needs to happen now
The case for investment is unusually strong, even by public health standards. The WHO estimates that scaling up ear and hearing care globally would cost less than US$1.40 per person per year, yet return nearly $16 for every dollar invested over a decade in health, productivity and broader societal gains.
What’s missing is political will. Governments need to fold hearing care into national health insurance schemes, remove the import tariffs that inflate hearing aid prices in many African countries, and invest in training and supporting community health workers.
And the few audiologists there are should be deployed to train, support and oversee these community-based services.
Multiplying the reach of hearing care across the hundreds of millions of people still waiting will take more than good technology. It will take the same ingredient our research keeps pointing back to: someone in the community, equipped and trusted to help.
De Wet Swanepoel – Professor in Audiology in the Department of Speech-Language Pathology and Audiology, University of Pretoria.
Study details
Hearing aids in low- and middle-income countries: from evidence to scale
De Wet Swanepoel, Caitlin Frisby & Vinay Manchaiah.
Published in Expert Review of Medical Devices on 14 July 2026
Abstract
Introduction
Hearing loss affects more than 1.5bn people globally, with nearly 80% of disabling cases in low- and middle-income countries (LMICs). Despite being the most established rehabilitation technology, fewer than 10% of those in need in LMICs possess them, with rates as low as 2% across Africa and Southeast Asia.
Areas covered
This review synthesises evidence on barriers to hearing aid access in LMICs, including workforce shortages, prohibitive costs and trade barriers, geographic centralisation, and stigma across internalised, social, and structural dimensions, and evaluates strategies to overcome them. These include task-sharing using community health workers (CHWs), mobile health (mHealth) and tele-audiology, preset and over-the-counter (OTC) hearing aids, rechargeable devices, mHealth adherence support, and health systems policy reforms.
Expert opinion
Closing this gap requires a shift toward decentralised, community-based care supported by digital technologies. Evidence supports CHW-facilitated hearing aid provision with structured counselling and mHealth acclimatisation support, as a feasible, effective, and acceptable rehabilitation model. Future progress depends on embedding hearing care within universal health coverage, reforming cost-inflating trade policies, and investing in implementation science to evaluate the fidelity, scalability, and sustainability of effective models. These models also apply to underserved populations in high-income countries.
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Bringing an African perspective to audiology
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