James Ackers-Johnson

The impact of delays on maternal and neonatal outcomes in Ugandan public health facilities: the role of absenteeism

Maternal mortality in low- and middle-income countries continues to remain high. The Ugandan Ministry of Health’s Strategic Plan suggests that little, if any, progress has been made in Uganda in terms of improvements in Maternal Health [Millennium Development Goal (MDG) 5] and, more specifically, in reducing maternal mortality. Furthermore, the UNDP report on the MDGs describes Uganda’s progress as ‘stagnant’. The importance of understanding the impact of delays on maternal and neonatal outcomes in low resource settings has been established for some time. Indeed, the ‘3-delays’ model has exposed the need for holistic multi-disciplinary approaches focused on systems change as much as clinical input. The model exposes the contribution of social factors shaping individual agency and care-seeking behaviour. It also identifies complex access issues which, when combined with the lack of timely and adequate care at referral facilities, contributes to extensive and damaging delays. It would be hard to find a piece of research on this topic that does not reference human resource factors or ‘staff shortages’ as a key component of this ‘puzzle’. Having said that, it is rare indeed to see these human resource factors explored in any detail. In the absence of detailed critique (implicit) ‘common sense’ presumptions prevail: namely that the economic conditions at national level lead to inadequacies in the supply of suitably qualified health professionals exacerbated by losses to international emigration. Eight years’ experience of action-research interventions in Uganda combining a range of methods has lead us to a rather stark conclusion: the single most important factor contributing to delays and associated adverse outcomes for mothers and babies in Uganda is the failure of doctors to be present at work during contracted hours. Failure to acknowledge and respond to this sensitive problem will ultimately undermine all other interventions including professional voluntarism which relies on local ‘co-presence’ to be effective. Important steps forward could be achieved within the current resource framework, if the political will existed. International NGOs have exacerbated this problem encouraging forms of internal ‘brain drain’ particularly among doctors. Arguably the system as it is rewards doctors for non-compliance resulting in massive resource inefficiencies.

Healthcare, frugal innovation, and professional voluntarism : a cost-benefit analysis

This book investigates what international placements of healthcare employees in low resource settings add to the UK workforce and the efficacy of its national health system. The authors present empirical data collected from a volunteer deployment project in Uganda focused on reducing maternal and new-born mortality and discuss the learning and experiential outcomes for UK health care professionals acting as long term volunteers in low resource settings. They also develop a model for structured placement that offers optimal learning and experiential outcomes and minimizes risk, while shedding new light on the role that international placements play as part of continuing professional development both in the UK and in other sending countries.

Introduction: Why Ethical Educational Placements?

This introductory chapter opens with a discussion of the processes of internationalisation and globalisation that frame the growth in interest in educational placements. It situates student mobility within this wider context before examining the meaning of the term ‘elective’ and examining the ethical issues that such placements raise.

Managing Reciprocity: No Harm Approaches to International Educational Placements

This final chapter summarises some of the key messages discussed in previous chapters to consider the meaning of ethics in the context of educational placements. It identifies some of the challenges associated with the commodification of placements through volunteer tourism distinguishing these from ‘Fair Trade Learning’ founded on reciprocity.

International Mobility and Learning in the UK National Health Service

This chapter sets the study of international placements for healthcare professionals in the wider context of knowledge mobilisation characterising mobile health workers as knowledge brokers. It then discusses the concept of ‘volunteer’ and how appropriate this term is to the study of placement learning. The term ‘professional volunteer’ is proposed as a compromise. Two key contextual dimensions are then outlined: first, global health and the needs of low-resource settings. Secondly, the challenges facing a resource constrained UK National Health Service.

Internationalisation and Placement Activity in the UK National Health Service

This chapter presents and discusses the findings from a survey conducted in the North West of England designed to gauge overall patterns of international exposure amongst all cadres of staff in the UK’s National Health Service.

The Ethical Educational Placement Project

This chapter introduces the reader to the Ethical Educational Placement (EEP) project, beginning with the background and its development. We then outline the project concept and detail its operation in terms of: how risk was assessed; how student recruitment and selection was organised; placement locations and student cohorts; placement structures and activities in Uganda and India; placement costs and student contributions; and project evaluation.

Managing Costs and Risks

This chapter identifies some of the ‘costs’ associated with health worker placements in low-resource settings; it begins with a discussion of the costs of covering staff time during placements and some of the fears surrounding skills ‘wastage’ before highlighting risk areas associated with such placements.

Student Learning on Ethical Educational Placements

This chapter focuses on what students learn from educational placements in low resource settings. The term ‘learning’ is used quite fluidly to embrace wider experiential learning – what students often describe as ‘life changing’ or ‘transformational’ impacts (Hudson and Inkson 2006) and more specific curriculum or employment relevant skills. We draw on reviewed literature, and qualitative data generated before, during and after placements, with students, placement leads at sending universities, long-term volunteer supervisors and educationalists/health workers in the host settings. The qualitative findings are supplemented with quantitative data gathered via an online student survey.

The ethics of educational healthcare placements in low and middle income countries : first do no harm?

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