From rights to reality: a critical review of policies governing services for deaf and hard-of-hearing children in LMICs

Introduction

The contemporary landscape of childhood disability is increasingly shaped by a global paradigm shift in which children with disabilities are no longer positioned as passive recipients of care, but as active holders of rights with agency, voice, and entitlement to equitable participation in society (Browne and Millar, 2016; Chataika et al., 2015; Clark, 2015). For children who are Deaf or hard-of-hearing (DHH), this shift is particularly complex and layered, as it sits at the intersection of disability rights and linguistic minority rights, requiring recognition not only of impairment-related needs but also of language, culture, and identity (Hopf et al., 2024; Trujillo Tanner et al., 2025). This dual positioning challenges traditional biomedical framings of hearing loss and necessitates a more holistic, rights-based and sociocultural approach to service provision. In this review, service provision refers to the continuum of health, educational, rehabilitative, communication, and support services available to DHH children and their families, including hearing screening, diagnostic assessment, amplification, early intervention, inclusive education, sign language access, and family-centered support.

Globally, approximately 34 million children require intervention for disabling hearing impairment (World Health Organization, 2026). The consequences of undetected or late-identified hearing loss are well established, with far-reaching implications for speech and language development, cognitive functioning, socio-emotional wellbeing, and educational attainment (Casoojee et al., 2025; Langbecker et al., 2020; Porcar-Gozalbo et al., 2024). These developmental disruptions often translate into long-term disparities in academic achievement, employment opportunities, and social inclusion, reinforcing cycles of disadvantage across the lifespan (Porcar-Gozalbo et al., 2024; Shojaei et al., 2016). Importantly, a substantial body of evidence demonstrates that early identification and timely intervention, supported by amplification technologies such as hearing aids and cochlear implants, alongside appropriate communication support, can significantly mitigate these outcomes (Khoza-Shangase, 2021; Orji et al., 2020; Phanguphangu et al., 2024). However, the realization of these benefits is unevenly distributed globally, with stark disparities between high-income countries (HICs) and low- and middle-income countries (LMICs) (Kanji et al., 2018; Rajanbabu et al., 2024).

In response to these inequities, the international community has developed a range of normative frameworks aimed at safeguarding the rights of DHH children and promoting inclusive, equitable systems of care (Moeller et al., 2024; Petrocchi-Bartal et al., 2025a,b; Snoddon and Underwood, 2017). In addition to broad human rights instruments, policy and practice guidance from organizations such as the WHO and the World Federation of the Deaf, together with the Family-Centered Early Intervention for Deaf/Hard of Hearing (FCEI-DHH) International Principles, emphasize early hearing detection and intervention (EHDI), family-centered care, language access, and equitable educational opportunities for DHH children (Moeller et al., 2024; World Health Organization, 2021; World Federation of the Deaf, 2023). The United Nations Convention on the Rights of the Child (CRC), the most widely ratified human rights treaty, affirms the right of every child to education, survival, development, and protection from discrimination (United Nations General Assembly and Canada Human Rights Directorate, 1991). However, the CRC has been critiqued for its reliance on a welfarist and needs-based framing, which may inadvertently position children with disabilities as beneficiaries of care rather than as rights-holders entitled to systemic inclusion (Byrne, 2012; Chilemba, 2019). In contrast, the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD), adopted in 2006, represents a more transformative shift toward a rights-based and social model of disability, emphasizing participation, accessibility, and equality (De Beco, 2014). Article 24 of the UNCRPD explicitly mandates inclusive education systems and recognizes the importance of sign language, linguistic identity, and appropriate educational environments for DHH individuals (UNICEF, 2017).

Despite these robust international commitments, their translation into practice remains uneven, particularly within African contexts and other LMICs, where structural constraints, competing health priorities, and systemic inequities shape service delivery (Khoza-Shangase, 2021; Orji et al., 2020; Phanguphangu et al., 2024; Joshi et al., 2023). In HICs, EHDI systems are typically well established, supported by legislative mandates and standardized protocols aligned with guidance from the World Health Organization (WHO) and the Joint Committee on Infant Hearing (JCIH) (Kanji et al., 2018). These systems have enabled early identification, often within the first months of life, and timely intervention, thereby improving developmental trajectories for DHH children. In contrast, in many LMICs, hearing impairment is frequently deprioritised in favor of conditions perceived as more immediately life-threatening, resulting in delayed identification, fragmented services, and limited access to early intervention (Petrocchi-Bartal et al., 2021, 2025a). South Africa provides a particularly illustrative example of this paradox. Despite a progressive constitutional and policy framework that strongly endorses disability rights and inclusion, implementation remains inconsistent, with the average age of identification for congenital hearing loss reported at approximately 30 months, significantly later than the internationally recommended benchmark of 1 month (Khoza-Shangase, 2019; Phanguphangu et al., 2025). This discrepancy highlights a broader systemic challenge across LMICs, where policy ambition is not matched by implementation capacity, giving rise to what has been termed the “implementation gap” (Petrocchi-Bartal et al., 2021, 2025a).

In parallel, the concept of inclusive education, a central pillar of rights-based frameworks, remains a site of considerable tension within DHH services. While intended to dismantle segregation and promote equity, inclusion in practice often takes the form of placement of DHH learners in mainstream classrooms without adequate support, including access to sign language, trained educators, or assistive technologies (Hayes and Bulat, 2017; Silvestri and Hartman, 2022). For DHH learners, this can result in linguistic deprivation, social isolation, and suboptimal academic outcomes (Hayes and Bulat, 2017; Silvestri and Hartman, 2022), raising critical questions about the extent to which inclusion, as currently implemented, fulfills its intended purpose. Importantly, emerging scholarship suggests that these implementation gaps cannot be understood solely through a resource lens. Rather, they are shaped by deeper structural and epistemic dynamics, including the privileging of Global North knowledge systems in policy design, the transfer of models without contextual adaptation, and entrenched inequities within health and education systems (Joshi et al., 2023; Khoza-Shangase, 2026; Rajanbabu et al., 2024). The concepts of epistemic injustice and policy transfer provide potentially useful interpretive lenses for understanding these dynamics. Epistemic injustice refers to the marginalization of local knowledge, lived experiences, languages, and cultural perspectives within policy development and implementation processes (Bhakuni and Abimbola, 2021; Ndlovu-Gatsheni, 2021), while policy transfer refers to the adoption of policy models developed in one context without sufficient adaptation to another (Evans and Davies, 1999; Evans, 2017). Although not always explicitly identified within the reviewed studies, these concepts offer a useful framework through which recurring implementation challenges may be interpreted. These factors collectively influence how policies are interpreted, prioritized, and operationalised in LMIC contexts.

Against this backdrop, this review seeks to critically interrogate the gap between rights-based policy commitments and the lived realities of DHH children. Specifically, the objectives of this review were to: (1) map the existing policy instruments governing services for DHH children; (2) assess the degree of alignment between national frameworks and international rights-based standards; (3) examine reported barriers affecting policy implementation; and (4) identify opportunities to strengthen the regulatory and service delivery environment. In addition, the review explores how broader structural, contextual, and knowledge-related factors may help explain persistent implementation gaps across health, education, and disability sectors. In doing so, the review aims to contribute to a more nuanced understanding of how rights can be translated into contextually relevant, equitable, and sustainable practices for DHH children, particularly within African and LMIC settings.

Methods

Study design

To ensure a rigorous, transparent, and analytically robust synthesis of the available evidence, this study adopted a systematic narrative review design (Sukhera, 2022). This approach was deemed appropriate given the heterogeneous nature of the literature, which spans qualitative studies, policy analysis, systematic reviews, and empirical research across diverse cultural and socio-economic contexts. Unlike traditional systematic reviews that prioritize homogeneity and quantitative synthesis, a systematic narrative review enables the integration of multiple forms of evidence while preserving contextual nuance (Sukhera, 2022), an essential consideration when examining policy implementation across LMIC settings. The review was conducted in a structured and transparent manner, guided by systematic review principles and reported using a PRISMA-style approach to enhance transparency in study identification, screening, eligibility assessment, and inclusion. Given the narrative nature of the review and the inclusion of diverse evidence types, the review did not seek statistical aggregation of findings, but rather thematic synthesis and critical interpretation of policy implementation experiences across contexts. Emphasis was placed on including high-quality peer-reviewed literature, that directly engaged with policy frameworks, implementation realities, and service delivery for DHH children.

Search strategy and databases

A comprehensive search strategy was implemented across five primary electronic databases: PubMed, Scopus, Web of Science, ScienceDirect, and EBSCOhost. To ensure adequate capture of regionally relevant and emerging scholarship, particularly from African contexts, Google Scholar was used as a supplementary search tool. The search was conducted between October 2025 and February 2026. This timeframe was selected to align with the emergence of EHDI policies and guidelines in several LMICs, including South Africa, where foundational frameworks began to appear in the early 2000s (Kanji et al., 2018). A 25-year window therefore allowed for a longitudinal examination of policy development and implementation trends.

Search strings were developed using combinations of Boolean operators and controlled vocabulary and included terms such as: “policies governing services for deaf and hard of hearing children,” “rights-based approach deaf children services,” “EHDI policy Africa,” “inclusive education policy vs practice deaf learners,” and “South African Sign Language official recognition.” These were adapted across databases using relevant indexing systems, including Medical Subject Headings (MeSH) such as Hearing Loss, Child, Health Policy, and Human Rights. Database-specific search strings are provided in Supplementary material 1. Searches were limited to English-language peer-reviewed journal articles published between 2000 and 2025. Google Scholar was used as a supplementary source to identify potentially relevant studies not captured through database searches, with the first 100 results screened according to relevance ranking. Four potentially relevant records were identified through this process and assessed alongside database-derived studies. The search strategy was specifically focused on children aged 0–18 years and their families, to capture the full continuum of early identification, intervention, and educational services.

Inclusion and exclusion criteria

To ensure analytical rigor and relevance to the study aims, the following inclusion and exclusion criteria were applied:

Inclusion criteria

• Peer-reviewed journal articles, including original empirical studies, systematic reviews, scoping reviews, and critical policy analyses.
• Studies explicitly addressing policy frameworks, implementation barriers, implementation enablers, or service delivery within health, education, disability, language, or rehabilitation systems for DHH children.
• Studies conducted in LMICs, with a particular emphasis on the African continent, while allowing for selected comparisons with HIC contexts.
• Articles published in English.

Exclusion criteria

• Non-peer-reviewed literature, including gray literature, theses, dissertations, and media reports.
• Studies focusing exclusively on clinical or surgical outcomes (e.g., of cochlear implant efficacy) without engagement with policy, systems, or service delivery contexts.
• Articles published prior to 2000.

Study selection and data extraction

The study selection process followed a structured multi-stage screening procedure. A total of 3,963 records were initially identified across all search sources. Following the removal of 839 duplicate records, 3,124 records remained for title and abstract screening. Of these, 3,000 records were excluded because they did not address DHH children, policy frameworks, implementation issues, or service delivery contexts. A total of 124 full-text articles were subsequently assessed for eligibility. Following full-text review, 99 articles were excluded due to one or more of the following reasons: no policy/service delivery focus (35), clinical outcomes only (24), adult populations only (14), not relevant to DHH children (11), commentary/editorial/non-empirical article (8), duplicate publication/overlapping dataset (4), not accessible in full text (3). Ultimately, 25 studies met the inclusion criteria and were included in the final synthesis, reflecting a balance of empirical, review-based, and policy-focused literature.

Both authors participated in study selection and full-text eligibility assessment. Screening decisions were discussed throughout the review process, and any disagreements regarding eligibility were resolved through discussion and consensus. Data extraction was undertaken using a standardized extraction framework developed specifically for this review. The data extraction framework was designed to align with the review objectives and to facilitate examination of both policy content and implementation realities. The following data elements were extracted from each study:

• Study Characteristics: Author(s), year of publication, country or region of focus, and study design, to contextualize the evidence base and identify geographic and methodological trends.
• Policy/Legislative Framework: The specific policy, act, or regulatory instrument governing services for DHH children.
• Policy Focus: The primary sectoral focus domain (e.g., health, education, disability rights, language policy), to assess cross-sectoral distribution of responsibilities.
• Key Rights Articulated: Explicit rights and entitlements outlined in the policy, including access to healthcare, education, early intervention, and language.
• EHDI Provisions: Inclusion of EHDI components, such as newborn hearing screening, early diagnosis, amplification, early intervention services, and timelines for identification and management.
• Inclusive Education Provisions: Policy directives related to educational placement, support services, and pedagogical approaches for DHH learners.
• Sign Language Recognition: Degree of formal recognition and operationalisation of sign language within policy frameworks.
• Implementation Barriers: Reported systemic, structural, and socio-cultural barriers to policy implementation.
• Implementation Outcomes: Evidence of how policies translate into practice, including service access, timing of identification, and educational outcomes.
• Alignment with UNCRPD: Extent to which policies and practices align with principles of the United Nations Convention on the Rights of Persons with Disabilities, particularly regarding inclusion, accessibility, and linguistic rights.
• Key Recommendations: Author-identified strategies for strengthening policy and service delivery.

Given the study objectives and emerging patterns within the literature, data extraction also captured evidence relevant to policy transfer, contextual adaptation, and knowledge-system influences where these were explicitly discussed by study authors.

The study selection process was documented using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-style flow diagram (Figure 1). The PRISMA-style flow diagram explicitly reports records identified through database searching and supplementary other searches, as well as the number of duplicate records removed prior to screening, thereby enhancing transparency in study selection.

Analytical sufficiency

Rather than applying saturation in the traditional qualitative research sense, this review considered analytical sufficiency within the evidence base. During study selection, data extraction, and thematic synthesis, recurring patterns relating to policy implementation gaps, EHDI challenges, inclusive education tensions, linguistic rights, and structural barriers were consistently identified across diverse contexts. Additional studies screened during the latter stages of the review did not yield substantially new thematic insights. The inclusion of 25 studies was therefore considered sufficient to support robust thematic synthesis and critical interpretation of policy implementation experiences across LMIC settings (Braun and Clarke, 2021).

Synthesis and quality appraisal

The extracted data (summarized in evidence Table 1) were analyzed using deductive thematic analysis (Proudfoot, 2023). This approach involved coding the data according to pre-defined analytical domains derived from the review objectives and extraction framework, including policy alignment, implementation barriers and enablers, service delivery gaps, implementation outcomes, and rights realization. Themes were developed through iterative comparison of findings across studies and subsequently refined to identify cross-cutting patterns, areas of convergence, and contextual differences between countries and policy domains. While epistemic injustice and policy transfer emerged as important interpretive concepts during synthesis, they were used primarily as analytical lenses through which to understand recurring implementation patterns rather than being treated as direct findings of the included studies.

Table 1. Comprehensive evidence synthesis of from rights to reality: a critical review of policies governing services for deaf and hard-of-hearing children.

Quality appraisal was conducted to assess the methodological rigor and credibility of included studies. Narrative reviews were evaluated using the Scale for the Assessment of Narrative Review Articles (SANRA). Systematic, scoping, and integrative reviews were appraised according to transparency, comprehensiveness, and methodological coherence. Qualitative, quantitative, and mixed-methods studies were assessed using established criteria relating to study design, sampling, data collection, analysis, and reporting quality (Tang et al., 2025). Studies were subsequently categorized as High, Moderate–High, Moderate, or Low quality. High-quality studies demonstrated strong methodological transparency, coherent analytical approaches, and clear reporting. Moderate-quality studies met most methodological criteria but exhibited some limitations in reporting or design. No studies were excluded on the basis of quality alone; however, quality ratings informed interpretation of findings during synthesis, with greater weight accorded to evidence derived from higher-quality studies. A detailed quality appraisal summary, including appraisal approach, quality ratings, and justification for ratings, is provided in Supplementary material 2.

Results

A total of 3,963 records were identified across database searching and supplementary sources. Following duplicate removal, 3,124 records remained and underwent title and abstract screening, consistent with the PRISMA-style study selection process presented in Figure 1. Screening resulted in the exclusion of 3,000 records that did not meet the review objectives. A total of 124 full-text articles were assessed for eligibility, of which 99 were excluded. Common reasons for exclusion included a primary focus on clinical outcomes without engagement with policy or service delivery issues, lack of relevance to DHH children, commentary/editorial/non-empirical article, duplicate publication/overlapping dataset, lack of full text accessibility. Ultimately, 25 studies met the inclusion criteria and were included in the final synthesis (Figure 1).

The PRISMA-style framework was used to transparently document the search and selection process for this systematic narrative review.

The included studies reflected a methodologically diverse and interdisciplinary evidence base, encompassing qualitative, quantitative, mixed-methods, review, and policy analysis designs. Geographically, the evidence was predominantly drawn from LMIC contexts, with a particularly strong concentration of studies from sub-Saharan Africa, especially South Africa, while a smaller number of studies from HICs such as Australia and the USA were included to provide comparative insight into more established EHDI systems of care (Khoza-Shangase and Maluleke 2025a; Maluleke et al., 2021; Naidoo and Khan, 2022; Sharma et al., 2022; Shearer et al., 2019). This geographic concentration should be considered when interpreting the findings, as the evidence base is weighted toward African and, more specifically, South African experiences of policy implementation.

Profile of included studies

The 25 included studies spanned multiple regions, including Africa, Asia, the Pacific, and selected HIC settings. A substantial proportion originated from African countries such as South Africa (Khoza-Shangase and Maluleke 2025a; Maluleke et al., 2021; Naidoo and Khan, 2022; Casoojee et al., 2024; Moustache and Makhoba 2024), Kenya (Piper et al., 2019; Ndegwa et al., 2024), Ghana (Oppong et al., 2024; Mills, 2019), Tanzania (Ndibalema, 2025), and Malawi (Mulwafu et al., 2017), reflecting a growing but still limited body of context-specific research on DHH services within LMICs. In addition, several studies adopted regional or global perspectives, particularly systematic and integrative reviews examining EHDI systems and disability policy frameworks across LMICs (Rajanbabu et al., 2024; Bright and Kuper, 2018; Petrocchi-Bartal et al., 2025a,b). Methodologically, the dataset included systematic reviews and policy analyses that provided macro-level insights into health systems and legislative frameworks (Petrocchi-Bartal et al., 2025a; Hussey et al., 2016), alongside qualitative and empirical studies that offered granular, contextually grounded accounts of service delivery and lived experiences. This combination enabled a multi-level analysis of both policy intent and implementation realities.

Across the dataset, studies clustered around three interrelated policy domains: (1) EHDI systems, (2) inclusive education and learning outcomes of DHH learners, and (3) broader rights-based, healthcare, and social policy frameworks, including disability and child rights policies (Petrocchi-Bartal et al., 2025a,b; Hussey et al., 2016), highlighting the inherently multisectoral nature of services for DHH children. Despite this multi-sectoral coverage, a consistent pattern emerged in which policy commitments were not matched by implementation, particularly within LMIC settings (Rajanbabu et al., 2024; Olusanya and Newton, 2007).

Table 1 provides a detailed synthesis of the included studies, summarizing study characteristics, policy frameworks, rights articulated, and the extent to which key domains; EHDI, inclusive education, and sign language recognition, are addressed, alongside reported barriers, outcomes, and alignment with international rights frameworks such as the UNCRPD.

Thematic analysis

Six interrelated themes were identified through the thematic analysis.

Theme 1: Strong Rights-Based Policy Commitments Across Contexts

Across the evidence base, there was consistent articulation of rights-based commitments to education, healthcare, and early intervention for DHH children. Multiple studies from Tanzania, Kenya, Ghana, and South Africa highlighted the recognition of the right to equitable and inclusive education, as well as access to appropriate learning environments (Ndibalema, 2025; Piper et al., 2019; Petrocchi-Bartal et al., 2025a). Similarly, the right to early identification and intervention was frequently embedded within policy frameworks, particularly in relation to EHDI systems in South Africa and Kenya (Khoza-Shangase and Maluleke 2025a; Ndegwa et al., 2024). Broader rights to healthcare and rehabilitation were also emphasized within disability and health policy contexts (Bright and Kuper, 2018). Importantly, many national frameworks demonstrated alignment with international rights instruments, particularly the UNCRPD, especially in relation to inclusion, accessibility, and participation (Hussey et al., 2016; Petrocchi-Bartal et al., 2025a,b). However, this alignment was predominantly normative, with several studies noting that while policies reflect global standards, their practical implementation remains limited, particularly in LMICs (Petrocchi-Bartal et al., 2025a; Rajanbabu et al., 2024; Olusanya and Newton, 2007).

Theme 2: Persistent Gaps in EHDI

A dominant finding across the dataset was the limited, fragmented, or emerging nature of EHDI systems in LMICs. Studies from Tanzania and the Solomon Islands reported the absence of formalized national EHDI programs, with identification of hearing loss often relying on parental suspicion or opportunistic detection (Jones et al., 2025; Ndibalema, 2025). In Kenya, screening initiatives were reported as emerging but lacking national scale and sustainability (Ndegwa et al., 2024). Systematic reviews examining LMIC contexts further highlighted that EHDI programs are often non-mandated, fragmented, and poorly integrated into health systems, resulting in significant variability in service provision (Joshi et al., 2023; Petrocchi-Bartal et al., 2025a,b; Rajanbabu et al., 2024). These systemic limitations translate into delayed identification of hearing loss and reduced service coverage (Joshi et al., 2023), with downstream implications for developmental outcomes (Khoza-Shangase and Maluleke 2025a; Naidoo and Khan, 2022). Despite these challenges, several implementation enablers were identified. These included the existence of national hearing care plans (Kenya), established professional guidelines (South Africa), family-centered intervention approaches, and integrated models of care that demonstrated improved outcomes where implemented (Casoojee et al., 2024; Maluleke, 2024; Ndegwa et al., 2024). In contrast, studies from Australia and the United States demonstrated strong and well-established, standardized EHDI systems, characterized by universal newborn hearing screening, early diagnosis, and timely intervention, which have significantly improved age of identification and developmental trajectories (Shearer et al., 2019; Sharma et al., 2022).

Theme 3: The Inclusion Paradox in Education Systems

While inclusive education was widely endorsed across policy frameworks, its implementation was highly variable and often ineffective, giving rise to what can be described as an “inclusion paradox.” Studies from Tanzania and the Solomon Islands reported weak or emerging inclusive education systems (Ndibalema, 2025; Jones et al., 2025), with limited capacity to adequately support DHH learners in mainstream settings (Jones et al., 2025; Ndibalema, 2025). Even in South Africa, where inclusive education policies are relatively well established, implementation remained inconsistent, with continued reliance on special schools or segregated units for DHH learners (Casoojee et al., 2024; Maluleke et al., 2021). Evidence from Kenya and Ghana indicated that this variability in implementation (Oppong et al., 2024; Piper et al., 2019) contributed to poor academic outcomes, including low literacy levels, particularly among DHH learners in under-resourced educational environments (Piper et al., 2019). In addition to academic challenges (Piper et al., 2019), studies reported social isolation and limited participation among DHH learners in mainstream schools, particularly where communication support was inadequate (Ndibalema, 2025). Overall, educational outcomes were frequently described as mixed or suboptimal, reflecting systemic gaps in teacher preparedness, resource allocation, and pedagogical adaptation (Moustache and Makhoba 2024). This pattern suggests a disconnect between policy intent and educational realities.

Theme 4: Emerging but Under-Resourced Linguistic Rights

Recognition of sign language as a fundamental component of DHH rights was increasingly evident across policy frameworks, particularly within African contexts (Oppong et al., 2024; Petrocchi-Bartal et al., 2025a). However, this recognition was often symbolic rather than operational, with limited evidence of systematic implementation (Ndibalema, 2025; Piper et al., 2019). Several studies highlighted that sign language was inconsistently integrated into service delivery systems, including education and early intervention programs (Ndibalema, 2025; Piper et al., 2019; Rajanbabu et al., 2024). In addition, there was a widespread shortage of trained interpreters and educators proficient in sign language, which significantly constrained access to communication (Hussey et al., 2016). As a result, despite formal recognition in some contexts, linguistic rights were not fully realized in practice, leading to restricted communication access and potential impacts on language development and educational participation (Rajanbabu et al., 2024).

Theme 5: Structural barriers undermining policy implementation

Across nearly all included studies, systemic and structural barriers were identified as key constraints on the implementation of policies for DHH children. These included financial and resource limitations (Bright and Kuper, 2018; Mulwafu et al., 2017), inadequate infrastructure, and shortages of trained personnel, particularly within health and education systems (Hatzopoulos et al., 2025; Rajanbabu et al., 2024). Geographic disparities further compounded these challenges, particularly in rural and remote regions of Africa and the Pacific, where access to specialized services was constrained by distance and infrastructure limitations (Jones et al., 2025). In addition, socio-cultural factors, including stigma and negative attitudes toward disability, were reported as significant barriers in Tanzania and Ghana (Mills, 2019; Ndibalema, 2025). These intersecting barriers contributed to poor service access, low utilization rates, and persistent inequities in outcomes, particularly for children in resource-constrained settings (Bright and Kuper, 2018; Kingsbury et al., 2022; Mulwafu et al., 2017).

Theme 6: The policy–practice gap as a cross-cutting theme

A central and pervasive finding across the dataset was the existence of a significant gap between policy commitments and real-world implementation realities. While many countries have developed comprehensive legislative and policy frameworks aligned with international standards, enforcement and operationalisation remain limited (Hussey et al., 2016; Petrocchi-Bartal et al., 2025a). This gap was evident across multiple contexts, including South Africa, Kenya, Ghana, Tanzania, Malawi, and broader LMIC settings, and was reflected in fragmented service delivery systems, inconsistent programme implementation, and limited intersectoral coordination (Rajanbabu et al., 2024). Consequently, key outcomes such as timely identification, access to early intervention, and equitable education were not consistently achieved (Khoza-Shangase and Maluleke 2025a; Kingsbury et al., 2022; Petrocchi-Bartal et al., 2025a,b).

Overall, the findings demonstrate that while rights-based frameworks are firmly established at the policy level, their translation into meaningful and equitable services for DHH children remains incomplete and uneven, particularly in resource-constrained LMIC settings. The evidence further suggests that implementation challenges transcend individual sectors and reflect broader systemic limitations within healthcare, education, and disability service systems.

Discussion

This review critically examined the disjuncture between rights-based policy commitments and the lived realities of DHH children, particularly within African and other LMIC contexts. Consistent with the review objectives, the findings demonstrated strong policy commitment to healthcare, early intervention, inclusive education, and linguistic rights, but limited translation of these commitments into practice. The review identified a persistent policy-practice gap characterized by fragmented EHDI systems, uneven implementation of inclusive education, under-resourced linguistic rights, and pervasive structural barriers. While these findings emerged directly from the evidence synthesis, they can be further understood through broader interpretive lenses, including epistemic injustice, policy transfer, and structural inequity. Crucially, the findings extend beyond descriptive gaps to highlight systemic patterns of misalignment between global policy norms and local implementation realities, which collectively undermine both the preventive intent of EHDI and the broader developmental goals of inclusive education.

From rights to reality: enduring gaps in implementation

Across the evidence base, national policies demonstrate strong alignment with the UNCRPD, particularly in articulating rights to healthcare, inclusive education, and participation (Department of Basic Education, 2001, 2014; Department of Social Development, 2015; National Planning Commission, 2012). However, this alignment remains largely normative rather than operational, with implementation in LMICs characterized by fragmentation, limited coverage, and weak enforcement (Olusanya and Newton, 2007; Rajanbabu et al., 2024). This distinction between normative alignment and functional implementation is critical, as it reveals that policy success is often measured symbolically rather than through service-level outcomes. This gap is most visible in EHDI systems, where policies frequently articulate early identification targets, but lack the infrastructure, workforce, and governance mechanisms required for execution (Khoza-Shangase and Maluleke 2025a; Naidoo and Khan, 2022). These delays undermine critical developmental windows and contribute to long-term disparities in language, cognition, and educational outcomes (Joshi et al., 2023; Maluleke et al., 2021). Crucially, the review also identified examples of implementation enablers, including professional practice guidelines, family-centered intervention models, integrated approaches to care, and emerging national hearing health strategies (Casoojee et al., 2024; Maluleke, 2024; Ndegwa et al., 2024). However, these initiatives were generally localized rather than system-wide and therefore insufficient to overcome broader structural constraints. Thus, the policy-practice gap should be understood not simply as implementation failure, but as a manifestation of systemic incongruence between policy ambition, system capacity, and contextual realities.

Epistemic injustice and the marginalization of context

Although epistemic injustice was not an explicit analytical category within the evidence extraction framework, it provides a useful interpretive lens through which to understand several of the patterns identified in this review. Epistemic injustice refers to the marginalization of particular forms of knowledge and experience within decision-making processes. In the context of DHH services, the findings suggest that local knowledge, linguistic diversity, caregiver perspectives, and community experiences are often insufficiently reflected in policy development and implementation. In many LMIC contexts, policies governing DHH services appear to be heavily influenced by Global North biomedical and technocentric models, which prioritize early detection and amplification but may inadequately account for linguistic diversity, cultural understandings of deafness, and systemic constraints (Joshi et al., 2023; Rajanbabu et al., 2024). This privileging of biomedical paradigms over sociocultural and linguistic perspectives constrains the scope of what is considered valid intervention, thereby narrowing the range of contextually appropriate solutions.

This pattern is particularly evident in the limited operationalisation of sign language within service delivery systems, despite increasing recognition of linguistic rights within policy frameworks (Oppong et al., 2024; Petrocchi-Bartal et al., 2025a). Similarly, tensions between spoken-language-driven approaches and sign language modalities, such as those reported in Kenya, suggest challenges in balancing biomedical and sociocultural understandings of deafness within policy implementation (Piper et al., 2019). Moreover, studies from South Africa highlighted how caregiver experiences relating to service access, affordability, and system navigation are not always adequately incorporated into policy development (Khoza-Shangase, 2019; Maluleke, 2024). Viewed through an epistemic justice lens, these findings suggest that implementation challenges may reflect not only resource constraints but also whose knowledge and experiences are prioritized within service systems.

Policy transfer and the limits of global models

A second interpretive lens that assists in understanding the review findings is policy transfer. Policy transfer refers to the movement of policies, frameworks, or models from one context to another, often across differing socioeconomic and health system environments (Khoza-Shangase, 2026). The findings of this review suggest that several policy frameworks governing DHH services in LMICs have been informed by international standards and models developed in HIC settings. The widespread adoption of benchmarks such as the “1–3–6” EHDI model exemplifies this dynamic. While these benchmarks have demonstrated effectiveness in HIC contexts (Sharma et al., 2022; Shearer et al., 2019), their application in LMICs often fails to account for workforce shortages, infrastructural limitations, competing health priorities, and weak referral systems (Hatzopoulos et al., 2025; Rajanbabu et al., 2024). This results in a form of policy isomorphism, where systems mimic global standards without possessing the structural conditions necessary for their success. As a result, policies may set aspirational but unattainable targets, creating a cycle in which systems are perceived as underperforming rather than being supported to achieve contextually meaningful progress. Evidence from South Africa and other LMICs demonstrates that, despite alignment with international benchmarks, implementation remains inconsistent and incomplete (Khoza-Shangase and Maluleke 2025a; Naidoo and Khan, 2022). This reinforces the argument that policy success in LMICs requires adaptive translation rather than direct transplantation, highlighting the need to shift from policy adoption to context-sensitive policy adaptation (Khoza-Shangase, 2026; Khoza-Shangase and Maluleke, 2025b).

Structural inequities shaping access and outcomes

The findings further highlight the role of structural inequities in shaping both access to services and developmental outcomes for DHH children. Within health systems, hearing care is frequently deprioritised relative to life-threatening conditions, resulting in limited screening programs, weak follow-up systems, and high rates of loss to follow-up (Joshi et al., 2023; Olusanya and Newton, 2007). This reflects broader priority-setting dynamics within constrained health systems, where preventive and disability-related services are systematically underfunded.

Within education systems, inclusive policies are often implemented in resource-constrained environments, characterized by insufficient teacher training, limited access to assistive technologies, and inadequate classroom support (Moustache and Makhoba 2024; Ndibalema, 2025). Consequently, inclusion may take the form of physical placement without meaningful participation, reinforcing rather than addressing educational exclusion. These systemic challenges are compounded by socioeconomic and geographic inequities, including cost barriers, rurality, and limited infrastructure, which disproportionately affect already marginalized populations (Bright and Kuper, 2018; Kingsbury et al., 2022). The convergence of these inequities produces cumulative disadvantage, where children most in need of services are least likely to access them, thereby perpetuating inequitable outcomes despite rights-based frameworks.

Reframing prevention in LMIC contexts

An important implication of these findings is the need to reconceptualise prevention within LMIC settings. While EHDI is typically framed as secondary prevention, its effectiveness is contingent on broader system readiness and integration. In contexts where early identification is inconsistent, prevention must be understood as multi-layered, encompassing primordial prevention (attending to the socio-economic determinants of health), primary prevention (e.g., addressing infectious and ototoxic causes of hearing loss), community-based identification strategies, and integration of hearing care into primary healthcare systems (Khoza-Shangase, 2022; Mulwafu et al., 2017; Olusanya and Newton, 2007). This expanded conceptualization shifts prevention from a narrow clinical focus to a systems-oriented approach embedded within public health and social determinants frameworks. Critically, prevention must also extend beyond biomedical outcomes to include linguistic access and educational participation, ensuring that DHH children develop functional communication and are able to engage meaningfully in society (Khoza-Shangase, 2025). This aligns with emerging evidence supporting family-centered, culturally and linguistically congruent intervention models, particularly within African contexts (Khoza-Shangase, 2025; Maluleke, 2024).

Toward contextually responsive and equitable systems

The findings of this review point toward the need for a fundamental reorientation of systems governing services for DHH children, particularly within LMIC contexts. Moving from policy commitment to meaningful implementation requires a shift toward contextually responsive and equity-oriented approaches. This reorientation necessitates simultaneous attention to governance, workforce capacity, service design, and community engagement, rather than isolated interventions. Strengthening governance and accountability mechanisms is critical to addressing the persistent policy-practice gap (Hussey et al., 2016), alongside sustained investment in human resources, including audiologists, educators, and sign language interpreters (Hatzopoulos et al., 2025). Equally important is the operationalisation of linguistic rights within service delivery systems. While sign language is increasingly recognized in policy, its integration into education, early intervention, and healthcare services remains limited (Oppong et al., 2024; Petrocchi-Bartal et al., 2025a). Bridging this gap requires institutionalizing linguistic access as a core component of service provision, rather than treating it as an adjunct or optional support. Furthermore, the review further suggests that development of locally relevant EHDI models is critical. Rather than replicating HIC benchmarks, policies must be adapted to reflect contextual realities, including system capacity, workforce availability, and population needs (Rajanbabu et al., 2024). Finally, meaningful engagement with caregivers, communities, and Deaf stakeholders is essential to ensure that services are aligned with lived experiences and sociocultural contexts (Khoza-Shangase, 2019). Such participatory approaches may also help address the epistemic imbalances discussed earlier by ensuring that local voices contribute directly to policy development and implementation. Collectively, these shifts are necessary if rights-based commitments are to be translated into tangible improvements in the lives of DHH children.

Limitations

This review should be interpreted in light of several limitations. First, the inclusion of only peer-reviewed literature published between 2000 and 2025 may have excluded relevant gray literature, including policy documents and programme reports, and implementation evaluations that are particularly important within LMIC contexts. Second, the heterogeneity of study designs and outcomes limited comparison across studies. Third, reliance on published evidence introduces the possibility of publication bias, with unsuccessful or unpublished programs potentially underrepresented. A further limitation relates to the geographic distribution of the evidence base. Although the review included studies from Africa, Asia, the Pacific, and broader LMIC contexts, a substantial proportion of the included evidence originated from South Africa. Consequently, some findings may reflect South African implementation realities more strongly than those of other LMIC settings. The exclusion of non-English studies may also have limited geographic and linguistic representation. Finally, as with all narrative syntheses, interpretation is influenced by reviewer judgement. Although systematic procedures, transparent selection processes, structured data extraction, and quality appraisal were employed to enhance rigor, the synthesis remains interpretive in nature.

Conclusion and actionable recommendations

This systematic narrative review demonstrates that although policies governing services for DHH children are generally aligned with international rights-based frameworks, particularly the UNCRPD, implementation remains inconsistent across many LMIC settings. Across the included studies, six interrelated patterns emerged: strong policy commitments, fragmented EHDI systems, inconsistent implementation of inclusive education, under-resourced linguistic rights, pervasive structural barriers, and a persistent policy–practice gap. Collectively, these findings indicate that legislative and policy commitments alone are insufficient to guarantee equitable access to services and meaningful participation for DHH children.

The evidence suggests that strengthening outcomes for DHH children requires a shift from policy formulation toward contextually responsive implementation. Based on the findings of this review, five priorities are recommended.

First, EHDI programs should be mandated, funded, and integrated into primary healthcare systems, with timelines and models adapted to local contexts rather than directly replicating high-income benchmarks. Second, prevention strategies must be expanded beyond early detection to include primordial prevention, primary prevention, community-based identification, and system-wide integration of hearing care. Third, inclusive education must be reframed to prioritize meaningful participation, supported by trained educators, appropriate resources, and flexible bilingual approaches that recognize both spoken and sign language modalities. Fourth, linguistic rights should be operationalised within service delivery systems, including investment in sign language training, interpreter services, and early access for families. Finally, policy development and implementation must address epistemic and structural inequities by incorporating local knowledge, engaging communities and caregivers in co-design processes, and strengthening governance and accountability mechanisms.

Ultimately, the challenge facing many LMICs is not the absence of policy commitments, but the translation of those commitments into accessible, equitable, and sustainable systems of care. Bridging this gap is essential if the rights articulated in national and international frameworks are to become lived realities for DHH children and their families.

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Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fauot.2026.1868604/full#supplementary-material

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Footnotes

Edited by: Adrian Fuente, Montreal University, Canada

Reviewed by: Carmen De Kock, University of Cape Town, South Africa

Ashifa Kariveliparambil, Gelisim University, Türkiye