La diversidad cultural en la ciudad global

As highlighted in 1.1, much of the research on the benefits of voluntarism for individual volunteers is based on volunteer or volunteer sending organisation perspectives (Lough and Carter–Black, 2015; Lyons et al., 2008). The findings presented in this section provide Ugandan perspectives of the benefits engaging with them have for volunteers. Several volunteer benefits consisting of a broad range of skills (or knowledge) thought to be ‘unique’ to Uganda and LICs more generally emerged. These benefits are collectively themed as ‘context–specific’ skills and are discussed next.

6.2.1 Context–specific Skills

Much of what Ugandans said volunteers gained in their settings consists of knowledge, skills, and awareness including creativity, innovation, and resilience, or what Laker and Powell (2011) broadly referred to as ‘soft skills’. Annette, a senior midwife, summarises these soft skills:

“…We [Ugandan health workers] have not got much but we make things unique to our health system…volunteers start making sense of us slowly but with our help they adjust and learn…I saw them [SVP] volunteers transform in front of my eyes; from not knowing where to start and what to do, to using latex glove as a urine bag…over time, volunteers become Ugandans! [laughs].” Working in a resource limited setting requires flexibility, imagination and ingenuity. Excelling in such settings requires the expertise of locals, and the determination of volunteers to accommodate new insights and perspectives. It appears that the plethora of health conditions and needs in Ugandan public health facilities provide some volunteers the opportunities to practice learning and others to acquire new insights. Leslie explains:

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“…almost everything about us [Ugandans and their health facilities] is new, interesting and sometimes shock to the volunteers. They are so many patients to see, so many health complications developing at any given time, and so many needs to be met on the ground every hour, everyday…skilled volunteers get the opportunity to practice their skills, and the not so skilled ones get to learn new skills from the moment they set foot in our health centres.”

A common example provided by Ugandans which was also briefly mentioned in 5.2.2.2 relates to knowledge of tropical conditions. There was a wider recognition that such conditions are not emphasised in most medical training in the NHS partly because tropical conditions are not very common in the UK. Uganda, according to Timothy, therefore, presents volunteers with:

“…a unique and an exciting environment for first time volunteers (and even repeat volunteers) because of the diversity of clinical conditions and needs patients present… volunteers gain diagnosis and treatment knowhow of wide range of conditions such as malaria and typhoid.”

Further supporting Timothy’s point above, ‘Engaging in Global Health, the framework for voluntary engagement in global health by UK health sector’, identified knowledge of tropical conditions as one of many areas UK health services can gain from LICs:

“…UK health services can benefit enormously from the knowledge and experience gained from work in low and middle–income countries. For example, health organisations and individuals can gain from the awareness of tropical diseases and global health challenges that affect us all.” (Cochrane et al; 2014, p.7).

Alice, a senior midwife, echoes Timothy’s notion of “unique” Uganda both in terms of its complexities and offerings. She says:

“…in [Ugandan] health facilities, many things happen at the same time: comorbid conditions, delayed births, preventable deaths…such challenging problems provide education experiences for volunteers.”

Alice provides a practical example of the complex challenges Ugandan health facilities present to volunteers, and how, with the support of Ugandans like her, some volunteers get the opportunity to gain on–the–job experience to contextualise and apply learning.

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“…as a first – time volunteer, she [volunteer midwife] could not cope working with us [Ugandan health workers]…everything seemed misplaced to her and understandably so…it was strange for her to see midwives taking blood and treating patients, and on several occasions, she thought we were taking things into our hands …slowly, she began to understand the need to be adaptable and make things happen in Uganda…later, she became flexible and learned how to test for malaria and tuberculosis…and enjoyed very much!”

In addition to applying learning, Susan, a senior midwife, suggests that the context (Uganda) itself is a “huge” attraction to volunteers with a view of experiencing “third world” health experience. She explains:

“…volunteers enjoy their placements in Uganda. Everything including working conditions seems to draw their attention and interest them… [name of SVP volunteer midwife withheld] once told me, being in Uganda itself is educational to her…she [volunteer midwife] said it felt like walking through her training in real life…”

Susan’s account is supported by a 2014 survey carried out by ‘Go Overseas’ which placed Uganda as the second most searched volunteer destination in Africa, and the tenth most popular volunteer destination in the world (see Appendix 2). Although Ugandans such as Susan did not elaborate why Uganda attracts volunteers other than it being “unique”, current literature on global health voluntarism point to several factors. Firstly, and perhaps most importantly, it is widely acknowledged that learning requires more than traditional classroom teaching (Crisp et al., 2013). Gedde et al. (2011) noted there is a growing realisation in the NHS and elsewhere to compliment classroom teaching and theory–driven knowledge acquisition with ‘on the–job– training to contextualise and apply learning. Equally, the focus on ‘lifelong’ learning in the UK requires Continuing Professional Development (CPD) to inform and underpin learning (Ackers et al., 2017).

Recognising the growing need in the global North to contextualise learning, Timothy suggests that the “friendly” and “sociable” atmosphere of Ugandan health facilities is key to realising both volunteers' on the–job–training and lifelong learning drives. He first notes how volunteers’ work in Ugandan health settings is “totally” different from that of the NHS, which, he describes as “highly structured” and “competitive”32_.

32 _{Timothy has been to the UK and appeared to have a good understanding of the structure of the}

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Timothy then adds that working in a relatively relaxed but highly demanding context enables volunteers to try “new” knowledge, coordinate care delivery, and among other things, gain clinical leadership skills33_{. He reflects his observation of a volunteer} doctor and says:

“…she [volunteer doctor] was keen to promote some clinical procedures to improve quality of care in [name of health facility removed]. With our support, she offered consultations to our staff and co–led most of our work particularly in theatre. In some cases, she developed clinical guidelines which are very useful to our staff and to our development.”

In the global health literature, clinical leadership skills include the ability to train, mentor, and empower diverse health workforce and coordinate care delivery (WHO, 2007). They also include designing and delivering intervention programmes that have positive effects on both health workers and members of local communities. Explaining this point, Timothy revisits his observation of the volunteer doctor:

“…she [volunteer doctor] trains, and mentors UK student volunteers hosted by us and some Ugandan student midwives. She personally led the development of infection control training and was a consultant on several areas including health education promotion in the community.”

The process of acquiring and/or applying knowledge in a different context (i.e. Uganda) requires various antecedents to happen successfully. In addition to the importance of a supportive environment (Metzler and Metz, 2010), and as Timothy suggested, it also requires ‘opportunities’ to access and embed learning. Upon closer observation, however, it became evident that such opportunity presented itself in two district ways. Firstly, it appeared that the noticeable absence of more senior Ugandans such as doctors in the health facilities provided highly skilled volunteers opportunities to fill this critical gap and coordinate some aspect of the health workforce and care delivery. There appears to be very little attempt (if any) on the part of the volunteers to gain insights into the root causes of doctors’ absence, which could have possibly brought to light some underlying socio–economic injustices along with an avenue from which to seek social justice.

33 _{The World Health Organisation (WHO) states that clinical leadership involves: “…providing}

direction to, and gaining commitment from, partners and staff, facilitating change and achieving better health services through efficient, creative and responsible deployment of people and other health resources.” (WHO, 2007, p.1).

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Instead, volunteers launch a gentle takeover and simply assume the roles of their senior Ugandan counterparts. I observed how some junior Ugandans felt uncomfortable with the domination of volunteers in some aspects of their care coordination and delivery and how powerless they appeared to voice their concerns in what is very hierarchical health system. Taken together, these Ugandan experiences confirm the need to combat economic injustice through the promotion of cultural justice to ensure volunteers do not knowingly or otherwise disparage and ‘other’ Ugandan hosts.

Secondly, the practice by some Ugandans of delegating ‘hard’ jobs to volunteers may have inadvertently provided volunteers opportunities to hone their skills and apply learning. In reality, however, such practice underlines racial stereotypes – the assumption that volunteers have better skill sets simply because they are white and from the UK. This stereotype itself is captured in 5.2.1 and reflected in studies on host communities in Southern Africa (e.g. Graham et al., 2011). The practice, also a recurring theme in the empirical chapters of this thesis, may also reflect an attempt by some Ugandans to entice and/or encourage volunteers to actively take part in service delivery and share the workload with them.

Whether planned or incidental, it appeared that Ugandan public health facilities provide volunteers opportunities to gain skills that are rarely accessible to junior staff within the NHS. In particular, more specialised skills such as clinical leadership gained in the context of LICs are looked upon favourably (within the NHS) if demonstrated by non–consultant returning volunteers (Gedde et al., 2011).

The following section explores benefits engaging with volunteers have for Ugandans as identified by Ugandans themselves.