Abstract
Background International medical volunteering has grown in recent decades. It has the potential to benefit and harm the volunteer and host countries; but there is a paucity of literature on the impacts of international medical volunteering and a need to find ways to optimise the benefits of such placements.
Aim In this study, one example of international medical volunteering was examined involving British GPs on short-term placements in Nepal. The intention was to explore the expectations and experiences of the local health workers, volunteers, and host organisation to try and understand what makes volunteer placements work.
Design Qualitative study of key informant interviews.
Setting Stakeholders of a short-term international medical volunteer (IMV) placement programme in Nepal.
Method Key informant interviews were carried out via face-to-face or telephone/internet interviews with five previous volunteers, three representatives from a non-governmental organisation providing placements, and five local health workers in Nepal who had had contact with the IMVs. Interviews were recorded, transcribed, and analysed using standard thematic framework approaches.
Results All the stakeholders had their own specific motives for participating in the IMV programme. The relationship between volunteers and the Nepalese health workers was complex and characterised by discrepant and occasionally unrealistic expectations. Managing these different expectations was challenging.
Conclusion Contextual issues and cultural differences are important considerations in medical volunteer programmes, and this study highlights the importance of robust preparation pre-placement for the volunteer and host to ensure positive outcomes.
INTRODUCTION
International volunteering has grown substantially in recent decades, facilitated in part by globalisation processes that have enabled greater movement of volunteers worldwide.1,2 This type of volunteering has also been facilitated considerably by the internet, which has helped volunteers find host placements abroad with greater ease than before. Volunteers, by definition, act of their own free will, with a greater goal in mind, be it a moral objective, a sense of personal achievement, or even a strategic career plan. Although altruism is an often cited motivator, volunteers working abroad also often benefit personally by gaining skills, knowledge, and experience, and through character development.3–6 As stated by the UK’s All Party Parliamentary Group on Global Health, international volunteering by health professionals is a means of advancing health globally by facilitating exchange of knowledge and skills between developed countries such as the UK and low and middle income countries.7
Over time the profile of the international volunteer has evolved, reflecting the changing demands of host countries. Developing countries no longer need low-skilled volunteers from developed countries, but instead require higher skilled professionals such as health professionals.2 International medical volunteers (IMVs) vary considerably by type and duration, for example long-term medical volunteers such as medical missionaries, and short-term expert consultants and trainers in a development context or humanitarian workers in emergency relief settings.8 Many non-governmental organisations (NGOs) operate in resource-constrained settings where they fill gaps in local health services.9 Not uncommonly, they rely on unpaid or self-funded volunteers to deliver services.10
International volunteering is often seen as an unqualified good, but this is not always true and there is a paucity of literature on its impact.1,11,12 IMVs on short-term placements may not make significant contributions to local health systems or populations.8 They may also fail to consider local needs and could undermine existing services.13–15 In addition, IMVs could acquire disproportionate political influence over local health policies.16 However, international volunteering can potentially benefit the volunteer and host; the challenge is to find ways to optimise this. In this study, one example of IMV is examined involving British GPs on short-term volunteer placements in Nepal. The intention was to explore the expectations and experiences of local health workers, volunteers, and NGO managers to understand what makes volunteer placements work.
METHOD
Short-term IMV placements in Nepal were examined with an international NGO, PHASE Worldwide.17 PHASE Worldwide is a development-focused NGO that runs primary healthcare programmes in Nepal. This includes a clinical skills teaching programme that involves British medical volunteers acting as ‘expert trainers’ providing teaching and supervision to Nepalese health workers. It aims to improve the quality of health care provided in primary healthcare facilities through sharing of the volunteers’ knowledge and skills with local health workers. IMVs were predominantly GPs and midwives on short-term placements of up to 2 weeks duration only. The programme is delivered in three remote rural districts of Nepal, with some locations only accessible after 4–5 days of travel by road and on foot.
How this fits in
International medical volunteer (IMV) placements can cause harm but also provide benefits to host countries. Expectations of the IMV and host need to be managed to ensure they are realistic. Adequate preparation is vital, especially for dealing with commonly faced cultural and contextual issues. Managed carefully, IMV placements can be a positive experience for all involved.
This study involved key informant interviews with previous medical volunteers, the NGO’s placement coordinators, and Nepali health workers with whom the IMVs were placed. A qualitative approach was adopted to explore expectations and experiences of the three stakeholder groups and to understand what led to a successful placement for all stakeholders concerned. Purposive sampling was employed to ensure that a breadth of views was obtained. In total, 13 participants were interviewed: five GPs, five local health workers, and three NGO representatives. IMVs who had volunteered within the previous 2 years (2009–2011) were contacted and invited to take part in the study. IMVs with recent experience of the programme were recruited to minimise recall bias. Five out of 11 GP volunteers contacted agreed to be interviewed. The local health workers were all five of the auxiliary nurse midwives (ANMs) currently supported by the NGO who had had experience of GP volunteers. The ANMs received 18-months’ basic training before being dispatched to rural health posts where they provide primary care services with a focus on maternal and child health. The NGO representatives were all of the managers involved with the volunteer programme.
All participants received an information leaflet and a verbal explanation of the study before interview. It was made clear at the outset that participation was voluntary and not remunerated. For Nepali participants, study information was provided and consent obtained via a translator. Signed consent was obtained from all participants. Interviews were conducted using a semi-structured interview schedule (available from the authors) composed of open-ended questions to explore and capture participants’ experiences and expectations. Interview schedules were reviewed by the researchers and pre-tested through a simulated interview: minor changes were made after pre-testing to improve the clarity of the questions asked. Interviews, each lasting less than 1 hour, took place between June and August 2011. Most interviews were conducted by telephone or as internet calls, and two were conducted face-to-face to suit the participants’ preferences. All interviews were audiotaped. Interviews in Nepali were translated at the time of interview and the English translation was transcribed afterwards.
Transcripts were then thematically analysed using a grounded theory approach. After familiarisation with the data, transcripts were scrutinised to identify themes that were then manually coded by one coder. These themes were subsequently grouped successively into higher thematic categories and then examined for patterns and linkages by two researchers. The study findings were triangulated with findings from the published literature.
RESULTS
Volunteer motives
Most IMVs had self-interested motives for volunteering, for example opportunity to travel, to work in a developing country setting in an ‘adventurous’ environment, or for altruistic reasons ‘to do some good. Generally, they described their experiences as positive, personally rewarding, and transformative, for example, some volunteers reported gaining self-confidence and a greater appreciation of the resources they have back in their home country:
‘I was looking for something different to do with my medical degree. I have been to Nepal before and I liked Nepal and I came across PHASE after I did a course in expedition medicine earlier in 2009. That looked like something very interesting, to give me the opportunity to travel, giving me the opportunity to do some good for a charity … How I would describe [my experience] … very fulfilling and I would recommend it to pretty much to any GP... .’
(IMV Male, GP5)
‘It was a real life change actually. It was … really so provoking and stimulating and scary experience ... I think in a way it made me confident and made me make decisions without back-up much more quickly. I think it made me rely on clinical decisions and actually made me bolder …’
(IMV Female, GP2)
‘Overall I think it had a very positive impact … for me personally. I was able to just switch off my life back home and also to put things in perspective when I came back.’
(IMV Male, GP3)
Contextual naivety
IMVs also reported a mismatch between what they expected and what they actually encountered. Some underestimated the poverty, basic living, and working conditions in which Nepali health workers operated, and the strenuous physical requirements for working in remote areas:
‘I think I was amazed how naive I was about the degree of poverty and the education in the country in the rural area ... I think I was quite naive to be frank with you, I think I was more naive about the practice and living conditions and how I found it, so that was quite an impact on me ... [I found] going to the clinic very eye opening-very basic but amazed what they the health workers were able to offer and how adaptable and flexible they were and that they were offering a basic kind of practice: general practice, minor surgeries, pharmacy, midwives skills and psychology … I’m a bit surprised, as my colleagues were, … compared to what we thought it might be.’
(IMV Female, GP2)
Some IMVs underestimated the skills and experience of the local health workers:
‘I thought overall the quality of the health workers was excellent and training was really really delightful because they had a lot of skills … It wasn’t you know what I would’ve thought — all these healthcare workers … have no medical degrees, they’re all midwives and nursing degree qualifications really, I mean they have been trained for 18 months maximum. And they were excellent they knew these topics extremely well.’
(IMV Male, GP5)
Others held unrealistic expectations of the impact they hoped to make and what was actually possible during their brief stay. This may have led them to subsequently question the actual benefit of their placement:
‘Can’t tell about [my] contribution. I don’t think we benefit them at all …’
(IMV Female, GP1)
‘When I went there I think I wanted to make a bigger difference if you know what I mean. I felt I could really you know make some bigger changes ... Possibly the amount of benefits may be a small amount … I certainly don’t think I would have changed their life dramatically but I’d like to think that I may have made a small difference.’
(IMV Male, GP3)
Of note, this was despite all volunteers receiving comprehensive pre-placement briefings and documents, and having had contact with previous volunteers.
Local health worker perspectives and expectations
Local health workers generally viewed the IMV placements positively. They reported that they ‘learned a lot of things’ and developed skills, especially around examination and diagnostic techniques, and clinical managing patients. They felt this improved their ability to do their jobs. Some also reported personal gains, such as character building and confidence boosts, as well as an opportunity to practice their English:
‘I think the biggest benefit I had was that I am really a lot more confident now than I was before … I feel like any problem that comes, any patient that comes, I have the confidence to deal with it now.’
(Female, Local health worker 2)
Moreover, they felt that the community’s trust in them was cemented by the knowledge that they were trained by British doctors:
‘The benefit … for the community has been because a doctor was sort of supervising us while we were diagnosing the patients. The community people have more confidence in the health workers now and feel that we are more experienced now that we are trained or supervised by a doctor.’
(Female, Local health worker 5)
There were also unmet expectations: some were disappointed that some IMVs lacked an awareness of local culture, language, and health policies:
‘… Before the doctors come here they should know the Nepali language and Nepali culture...’
(Female, Local health worker 5)
In addition, they felt that the IMVs did not always understand their training needs:
‘… When doctors come here they should really know what the policies of our government are as well. Their techniques and the government techniques should not clash later on … The doctor should really know the Ministry of Health in Nepal and what the policies are here so that they can go according to that as well … The volunteer doctor should know the weaknesses of all the trainees beforehand. So like weaknesses as in difficulties that they have so they can make a syllabus out of that rather than make a syllabus when the training starts.’
(Female, Local health worker 2)
Two-way relationship
Although there were discrepancies in expectations for the IMVs and local health workers, the benefits were not one-sided and there were mutual benefits enjoyed:
‘… There are lots to be gained and, as I say, the learning from the work itself because it will be a different spectrum of disease to what [the GP volunteers] have seen before. The level of resources is very different too, to what we have [in the UK]. So much more demands placed on your basic clinical skills without recourse to investigations and laboratory in the background … It is not a one-way street [but] a two-way learning process. … We want the right GPs to be going. We want GPs who have the skills to be able to provide what we need in Nepal but they will be gaining a great deal from it.’
(Male, NGO representative 3)
IMVs offered local health workers tailored one-on-one teaching and coaching, helped them to practice and improve their management decisions, and built their confidence in their clinical skills. In return, Nepalese health workers taught IMVs about their country, customs, and language, and helped to orientate them in the challenging resource-constrained context in which they worked. The benefits to health workers were greatest when IMVs adapted their training to the local context rather than adhering to a pre-set curriculum:
‘… My expectations [of the volunteers] matched the experience because the doctors did not teach from their own curriculum, but about what we had difficulties with and what we had problems with. So what I was expecting was what I actually learned … I had a good experience.’
(Female, Local health worker 3)
Managing expectations
The NGO organising the short-term volunteer placements played an important role managing the expectations of all stakeholders. The NGO wanted the health workers and IMVs to benefit from the placement. They expected IMVs to teach the health workers new skills and transfer knowledge, while also enjoying the experience in the process:
‘It is very useful from the Nepalese point of view because … there are quite of few … foreign doctor or foreign surgeons or foreign trainers … they come here and then they setup a big ‘health camp’ … but when they go they don’t have anything to follow. … But for our programme what happens is (the volunteers) transfer some skills to the local health worker. So when (the volunteers) go back our staff are still there who are trained by good people so, so I feel it is a really good programme.’
(Male, NGO representative 2)
‘I expect that [the local health workers] use the time that the trainers are with them to ask as many questions as they can and learn as many new skills as they can in that time. Mostly, really to ask about specific cases that they dealt with and specific things they are not sure about. And I do expect them to actually change their practice according to what they have been taught.’
(Female, NGO representative 1)
This was balanced against the NGO’s agenda: they were concerned about programme sustainability and impact, and saw the placement programme as an investment to build and support the local health workforce:
‘For the organisation there are several benefits. Obviously the ultimate aim for our organisation is to actually improve the situation for people in those remote target villages and the better [health] worker … obviously [does] a better job … improving things for the target population. But obviously to an extent also having trusted and competent health workers benefits the reputation of the organisation as well … Having a good training programme actually attracts good staff so that when we advertise for new posts we are more likely to attract good staff …’
(Female, NGO representative 1)
They were also cognisant of the need to ensure that IMVs and local health workers were adequately prepared in advance to optimise the benefits of the placement, as well as the value of feedback from previous placements to help improve subsequent ones:
‘I think there is still room for improvement in the preparation we give to the GPs. And I think we got it better than a lot of organisations because we do have guidelines … We always prepare beforehand, we always send them reports from previous volunteers so they’ve got a very clear idea of what to expect.’
(Female, NGO representative 1)
‘I think it is very important that we think very carefully about what we are trying to achieve so that’s [part] of the process ... and it starts with the preparations.’
(Male, NGO representative 3)
DISCUSSION
Summary
The relationship among IMVs, local health workers, and NGO was akin to a transaction: all sides had pre-conceived expectations and implicitly sought some gain from the placement. These expectations were not always articulated. In this study, local health workers sought a transfer of knowledge and skills, support and coaching, and an opportunity to practice their language skills. IMVs, on the other hand, sought an opportunity to travel, experience, and work in a different setting, and to make a positive impact. The placement organisers, who sought to optimise mutual benefits for all and to minimise harm, faced a challenging task of managing volunteers’ expectations. This was especially because most volunteers held a degree of ignorance that has been described as a mix of ‘naïve realism and ethnocentrism’.13
Despite knowledge being exchanged, expectations were not always fulfilled. This discrepancy in understanding and unmet expectations could adversely colour participants’ views of the short-term volunteer scheme. The unfulfilled expectations were caused, in part, by contextual and cultural differences between host and volunteer of which often neither party is fully cognisant. The volunteer placement is, therefore, not a simple one-way knowledge transaction but a complex social process between host and volunteer.18 Considering and balancing competing expectations was, therefore, a crucial determinant of the perceived success of the programme. For IMV placements to work, host and volunteer need to have realistic goals and a common understanding of the aims of the placement.
More difficult to measure are the wider impacts of short-term placements.13 Indeed, international volunteering can have unintended consequences, beneficial and negative, for volunteers and locals, which were not always anticipated.13,19 Short-term placements could lead to unrealistic patient and community expectations of local health services and create unrealistic standards that are difficult to attain or maintain.20 They could also lead to local health inequities as not all health posts receive support from the IMVs or NGO. That said, in this study the impacts of the short-term placement for both volunteer and beneficiary were generally viewed positively.
Strengths and limitations
The need for independent translation was identified before starting the interviews, but for pragmatic reasons this was limited to using a translator employed by PHASE. It is acknowledged that this could have introduced potential bias during the interviews, leading to under-reporting of negative opinions. The other potential bias was ‘courtesy bias’, a cultural phenomenon whereby participants may give answers they believed to be what the interviewer wanted to hear so as not to offend. This could affect the reliability of the obtained data. Although the study was alert to the possibilities of courtesy and translator bias, it was found that research participants spoke freely during interviews and gave a good range of responses including critical comments, which suggest that interviews were fairly open and honest.
Ideally it would have been useful to triangulate findings with other programme indicators as well as with community feedback. For logistical reasons, however, this information could not be obtained. Neither was it possible to compare with other UK–Nepal health partnerships as information from these programmes was not available, and it was unclear whether they were sufficiently similar to enable valid comparisons to be made.
Comparison with existing literature
Volunteers reported experiencing ‘culture shock’ because of the contextual differences and challenges faced in resource-poor settings. Moreover, IMVs from developed countries are not necessarily equipped to work in developing country settings where the disease profiles and resource availabilities are different.8,15,21 As reported elsewhere, robust pre-placement preparations are, therefore, essential to ensure that volunteers are well-informed of the context in which they will be operating.8,13,22,23 There is also a need for local health workers to receive some form of briefing as to what to expect from a visiting IMV. There is also a danger that the local workers are not critical enough of the training and knowledge given to them by the IMVs. However, pre-placement briefings for the IMVs or local health workers are not always done, and this would especially be the case for independent volunteers on ad hoc self-arranged placements.21 Recommendations of 10 key issues to be considered during pre-placement preparations, which may help optimise international volunteer schemes, are shown in Box 1.
Pre-placement checklist for international medical volunteer training placements abroad
For the international volunteer:
Basic language skills and cultural orientation
Briefing covering health system, local health policies, and clinical guidelines
Explanation of the roles, skill level, and learning needs of the local trainee
Clear articulation of aims and objectives of the placement, and tasks to be undertaken
Emphasis on need for flexibility and adaptation of work to suit local context
For the local health worker (to be trained):
Clarify health worker’s expectations as well as expectations of the medical volunteer
Clear articulation of aims and objectives of the placement, and role of the volunteer
For the hosting organisation:
Conduct learning needs assessment of the trainees
Ensure volunteer has appropriate skills and qualifications to deliver the training
Incorporate feedback from previous placements to improve the next placement
Another concern raised elsewhere was that the services offered by volunteers may not be what the host community really needs or wants.13,24 It is inappropriate to re-create medical practice from high-income country settings in resource-poor settings. Programmes that pay inadequate attention to local culture and conditions may fail to consider the potential incompatibility and harmful effects that can be produced.14 In addition, international volunteer programmes risk reinforcing pre-existing dependency on foreign aid and worsening health inequalities.12 Ideally, the health needs for the host community would have been determined in advance, and IMVs with relevant skills are then matched appropriately to the need. In reality, many NGOs may not have at their disposal volunteers with a comprehensive range of skills from which to choose.
Implications for research and practice
Between 2010 and 2012, more than 5120 foreign medical professionals travelled to Nepal on short-term placements.25 IMV can benefit the volunteer and the receiving country. However, the desire to do good does not make one immune from being ineffective or even harmful, and the benefits accrued are lopsided in favour of the volunteer.2,12 IMVs, therefore, retain a degree of social responsibility for what they do elsewhere.21 Moreover, this emphasises the need for host countries to consider issues of governance and regulation of short-term medical volunteering to ensure that they deliver safe and effective care.26
The study findings also reinforce the importance of robust pre-placement preparations to effectively manage expectations of all stakeholders. This requires active involvement by all stakeholders in planning and implementation. IMV placements also benefit from having discrete, achievable, and clearly stated aims to keep the placements focused.20 The collection and application of feedback from hosts and volunteers, as well as assessing the impact of such placements, are vital for ensuring that potential harms are mitigated and beneficial outcomes maximised. Successful exchanges are those that work both ways, where there is a genuine sharing of knowledge, experiences, and ideas, with a commitment to building longer-term relationships.15 Applied carefully and thoughtfully, IMVs can be a small part of the solution to the problem of clinical skill shortages afflicting many resource-poor health systems.
Acknowledgments
We would like to thank the staff of PHASE Worldwide, the GP volunteers with the programme, and Nepali health workers who took part in this study.
Notes
Funding
None.
Ethical approval
Ethical approval was provided by the School of Health and Related Research’s Research Ethics Committee at the University of Sheffield, ref: 0471/CAO.
Provenance
Freely submitted; externally peer reviewed.
Competing interests
Dr Gerda Pohl works as a trustee and volunteer for PHASE Worldwide and has not received any payments for carrying out this study. To safeguard against possible bias, she was not involved in the analysis of the interviews.
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- Received October 24, 2013.
- Revision requested November 26, 2013.
- Accepted January 28, 2014.
- © British Journal of General Practice 2014