Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS (2005)

John Shippee

Shippee Consulting

For the purpose of this paper, representatives from U.S. organizations who send volunteers to work overseas in health programs were surveyed. The survey was intended as a preliminary exploration of the experience of such organizations in sending volunteer health professionals to resource poor countries. Special attention was given to organizations deploying volunteers to work in HIV/AIDS. For several reasons, this effort must be considered a preliminary study that points (perhaps strongly) in certain directions, rather than an authoritative undertaking.

More than 80 organizations were considered for inclusion, and 66 were contacted primarily through e-mail. A survey and cover letter from the investigator and study director were emailed to each participant and followed up with a telephone call from the investigator. Most surveys were completed as telephone interviews. Of the 66 organizations contacted, 31 completed the full survey; and 30 of the 31 organizations completing the survey send volunteer medical professionals. Responses to the survey have been compiled for this report.

The organizations contacted and surveyed fell into the eight categories as outlined in Table D-1.

As measured by their overall annual budgets (gifts in kind excluded), the respondents ranged from small missionary organizations annually funded at less than $200,000 to large international organizations that have global budgets of roughly $1.5 billion. Many of these organizations have dedicated funding for the “battle against HIV/AIDS.”

The lengths of service for volunteers in each organization varied from a few weeks to years. Renewable multiyear agreements with formalized contracts were available for some missionary organizations and university medical faculties. For the purpose of this study, organizations were divided into short (under 2 months), medium (2 to 6 months), and long-term volunteer (longer than 6 month) assignments.

Compensation by these organizations to medical professionals also varied. This study included but was not limited to organizations that offered no remuneration or subsistence level stipends.

Respondents identified a number of challenges to long-term partnering. This category includes obstacles to cooperation that can arise as a result of differences in organizational structure, expectations, and cultures between partnering organizations.

Cited challenges include overly onerous national and local governmental bureaucracy; difficulty obtaining in-country work permits; and trouble understanding complex local medical licensing regulations. Other reported barriers were the inability to cash traveler’s checks and use credit cards.

Less frequently, respondents reported difficulty in following the rules and procedures of their own and/or other international agencies and governments. These included such matters as difficulties in transferring funds to host and partner organizations; insistence on introducing antiretroviral therapy into treatment programs already using other regimens; and “overevaluation” that could mean having to carry out several different evaluations by related sponsoring agencies assessing essentially the same organizational procedures.

Communication obstacles in international partnership arrangements can take a variety of forms. Examples include lack of clarity regarding volunteer expectations (doctors expecting to focus on direct care being asked to administer programs); differences in the belief of how best to carry out certain administrative procedures; unmet expectations regarding volunteers’ working or living conditions; and simple procedural misunderstandings between international partners.

Another communication obstacle—spoken or unspoken—can be the perceived or real arrogance or unwillingness to communicate on the part of very large organizations. One respondent cited this as an impediment and described their organization’s efforts (not always fully successful) to overcome this communication obstacle with their often much smaller partners.

Closely related to poor communication was the frequently cited challenge involving a lack of mutual clarity regarding goals and expectations. Each party in a partnership (including volunteers who are helping to implement it) needs to have a clear and explicit understanding of the extent and limitations of their mission, objectives, and responsibilities. Many problems can arise when this is not clearly stated at the beginning of a partnership and redefined as new situations arise. For example, considerable disruption can ensue if an international partner cannot provide promised funding in a

timely manner or local partners have exaggerated expectations of the international partner’s funding capabilities. Similarly, international volunteers (or employees) expecting to find Western medical supplies and efficient documentation systems in developing countries will likely find major frustrations with their host organization’s working environment. This difficulty is compounded in partnering situations in which the international organization and local partners enter into agreements that do not take into account the very different “health worlds” or medical cultures from which each come.

Volunteers and particularly those lacking relevant international experience, will require reliable local supervision, support, and orientation to situations and circumstances. Volunteers who do not have proper supervision may feel isolated, unable to use their skills, and frustrated in their work. Local partners, on the other hand, may simply not have the time (or in some cases, the skills) to provide a sufficient level of supervision and orientation needed for most international volunteers.

Partnerships are often constrained by funding. When the funding cycle ends, new sources are needed to sustain a long-term relationship. Creating false expectations that funding will continue without time limitations can leave a partner organization in a precarious situation, which is particularly dangerous in HIV/AIDS treatment partnerships. Once a support level for specific HIV/AIDS activities (i.e., ARV provision, prevention education, or orphan support) has been established, it must be maintained either nationally, internationally, or locally or else consequences, such as heightened ARV resistance, may worsen an already challenging situation.

Problems with local infrastructure were commonly reported challenges to effective partnerships. Many developing countries have inadequate medical infrastructures and technological capabilities. Communication technology is similarly poor in many low-income nations making consulting and other professional support at long distances difficult to impossible.

One respondent with extensive project planning and implementation experience indicated a need for local skills training particularly at the district level since inadequate planning can jeopardize district as well as local level projects.

Several respondents emphasized high rates of indigenous staff and key contact turnover as an obstacle to successful partnering. This can occur for numerous reasons, among them political change, better job opportunities elsewhere, and the impact of the pandemic itself.

A number of potential challenges arise out of the contexts and cultures in which partnering takes place. Those mentioned or discussed by respondents included the following:

In addition to different levels of infrastructure and overall cultural differences, a number of respondents pointed out, directly and indirectly, that partnering organizations can expect to encounter different medical cultures and “health worlds” between developed and developing countries. For example, medical presentations of patients’ status in developing countries may be much more abbreviated and less analytical; medical record keeping may be considerably less formal and detailed; the level of deference to professionals may differ between partners; and traditional birth attendants and healers may have a much greater role to play in HIV/AIDS prevention and treatment than some practitioners are accustomed to.

The lack of expected local enthusiasm for programs because of chronic community level depression due to HIV/AIDS and its accompanying survival challenges was emphasized by a representative from a major international nongovernmental organization and two other smaller organizations. They believe a multifaceted approach that helps inspire and reinforce hope to community members is needed if such communities are to achieve specific HIV treatment, prevention, and care goals.

Battles over ownership, responsibility, and control were cited as impediments to effective partnering.

The risk of isolation was a recognized challenge particularly for volunteers who are deployed without a clearly defined position in the host country and no receiving infrastructure from which they can be oriented to their new environment. This infrastructure might include a community of peers, host-country counterparts, and expatriates.

The prevalence of HIV/AIDS, poor working and living conditions, lack of personal connections, and other frustrations that may arise from international partnering can have a negative impact on the morale of deployed volunteers and the organization as a whole, thus harming the partnering relationship.

Based on responses in the survey, it appears that the challenges outlined above fall into four basic categories. These categories include:

• Realistic expectations

• Organizational responses

• Volunteer placement and support

• Host organization considerations

Many respondents suggested that having patience with host and partner organizations and allowing their requirements to set the pace for scaling-up operations will build a stronger relationship in the end.

Realistic budgets that provide room for unexpected costs may be better positioned to achieve preset goals. Often, unanticipated extra expenses (such as the need for building physical infrastructure) have been met through private donations.

This may include actively countering HIV/AIDS based stigmatization, identifying powerful community leaders and community programs that support both the program and have a generally more positive outlook, and enlisting (as many local and internationally partnered organizations have done) traditional and nontraditional educational and entertainment in program activities.

A “normal curve” of successful interventions may be the best that can be expected. An organization experienced with operational evaluation of HIV/AIDS projects stated that roughly 25 percent of partnership driven projects fully meet or exceed expectations, 50 percent meet most expectations, and 25 percent fail. Accomplishing project outcomes should therefore not be the only measure of success.

A number of respondents emphasized that patience is needed when working with partners particularly with those from economically deprived countries. Attempting to bypass local decision makers or procedures; avoiding sometimes time-consuming meetings and activities; failing to develop local relationships; and failing to identify reliable and effective local counterparts can lead to greater frustration, and ultimately, failure of the project.

Partnerships should be based on mutual benefit, respect, shared values, and goals. Those that start small and grow over time have a better chance of maintaining a successful, long-term relationship. This was emphasized by the representative of a university-to-hospital partnership with over 15 years of experience in partnering.

Understand the communication process prior to engaging in a partnership. It may be useful to study and review progress reports from successful partnerships. A number of these successes have been in the field for more

than 15 years and know how to effectively communicate with their partners. They may also have reliable information concerning potential local counterparts who can be most helpful in maintaining an open dialogue between partners.

Patience and some humility are required for maintaining a successful long-term relationship. The local partner organization can often teach the international counterpart about working in its context. Following the local lead in such situations can build up a reserve of trust and mutual respect that can be quite useful later on. Experience, evaluation, and reevaluation are excellent learning tools.

Strategic planning and program evaluation are necessary skills for both short-term success and long-term sustainability of partnerships in local and international contexts. Continued project growth and support are contingent upon excellent strategies and reliable evaluation.

A number of respondents stated that to work effectively, volunteers need personal, professional, and administrative support networks. Many successful volunteer organizations whether secular or faith based, reported having most of these systems in place.

Survey results also suggested that sending volunteers to un-vetted or poorly vetted receiving organizations will often create problems. The three surveyed organizations with higher than average attrition rates acted mostly as clearinghouses for requesting organizations; focused a large part of their effort on emergency relief; or expected volunteers to function independently.

Linking volunteers with local counterparts can be useful in orienting them to their new living and working situations. They can provide mediating services between their in-country colleagues’ systems and temporary

personnel (both short and long-term) who might otherwise spend weeks or months trying to accomplish what the counterpart can do in one or two telephone calls. Counterparts can also be helpful in identifying potential and alerting volunteers to potential obstacles to accomplishing their goal.

Because such people are so valuable (and local staff turnover can be high), it is important to insure they remain on-site for considerable periods. If they must leave, they should be involved in identifying and training their successor. As volunteer programs expand or develop new sites, such persons may be helpful in identifying local talent and preexisting networks at these new sites.

Several respondents recommended placing a volunteer coordinator or supervisor in the host country. These people would work in a service similar capacity to the local counterparts. The least expensive way of doing this is to find someone in the receiving organization who is willing and able work on a part time basis and has the appropriate experience. A longer-term volunteer or former volunteer may be appropriate as well.

It was suggested that long-term follow-through can often be a weakness of local partner organizations—a particularly important consideration in HIV/AIDS related programs. Volunteers should be trained to support their host country counterparts in an effort to maintain a sustained commitment to the program.

A number of respondents commented that a resource commitment on the part of the host organization is an important indicator of commitment to a volunteer program. The counterpart organization could provide something in terms of tangible benefits, according to their abilities (i.e., housing) to volunteers as an indication of commitment to the program. Commitment to the partnership could

Several respondents pointed out the direct costs and opportunity costs of hosting and using volunteers in terms of lost work and resources that

could otherwise be used in developing local capacity and sustainability. The danger of fostering dependency on overseas volunteers is also implied in such comments. Therefore, the value of using volunteers (especially short-term people) needs to be balanced against the local opportunity costs (in terms of time and effort expended) of hosting them.

Volunteers are expensive. For example, it costs roughly $75,000 per year to keep a Peace Corps volunteer in the field. The cost for a midcareer M.D. or Ph.D. may easily be twice that amount when adding other expenses such as a modest salary, family housing costs, home leave, children’s education costs, and health insurance.

Ten doctors for 1 year, exclusive of program costs can be budgeted at $1.5 million: 1.25 percent of the annual PEPFAR budget for an average country. Sending one such doctor (including salary) for a 2-week stay to evaluate or consult on existing programs can cost at least $8,000. A 2-week church mission trip to Africa can cost $40,000.

Many organizations prefer to fund and assist in-country organizations and counterparts achieve sustainability on their own, by using in-country personnel and consultants to supplement their own workers, volunteers, and expatriate staff.

First time volunteers (except for short-term emergency workers and specialized teams) require orientation, hosting, and support systems. All of this takes time and scarce personnel away from service provision and capacity building. These costs that have to be balanced against the value added by the work and relationship building carried out by volunteers at various levels.

The United States and other economically advantaged countries are not the only source of skilled workers for developing countries and not always the most appropriate (especially in the case of first time volunteers). Though

scarce, a potential supply of skilled staff exist in most countries themselves. Other skilled workers may come from countries where the health culture is closer to that of the host country such as Brazil, Mexico, or India.

Most of the groups surveyed reported sending short-term doctoral level professionals and nursing volunteers. However, there may be an equal if not greater need for professionals in other areas that support building capacity of the healthcare infrastructure. These might include public health, medical records (particularly important in relation to HIV/AIDS), laboratory and pharmaceutical infrastructure, and human resources management.

Recruitment of volunteer medical professionals may be difficult, especially for medium and long-term assignments. Early career medical doctors and nurses may have young families and more often than not have large student loan obligations. Midcareer professionals who are willing to interrupt careers and disrupt family life for these assignments can be hard to find. University faculty, for whom such assignments can advance their careers and may be part of their paid professional activities, are a fairly frequent exception. A number of university-based respondents reported having more candidates for these assignments than their programs could accommodate.

Emergency disasters such as the recent hurricane season in Florida, Hurricane Mitch in 1998, and the Asian Tsunami appear to have taken some of the focus away from the more chronic health problems like the HIV/AIDS pandemic. Although chronic infectious diseases have far-reaching and damaging long-term consequences, they do not appear to have as high status for volunteers and have more complex volunteering requirements.

• Most respondents engage in multiple recruitment approaches.

• The Internet is a principal recruiting method, as are returned volunteers and word of mouth (particularly for university based programs).

• University based programs and others cited educational institutions as good sources of volunteer program participants. Universities reported having many more interested faculty than their programs can place.

• Faith-based programs mention faith communities and faith-based organizational networks and news media as good sources. Like university-based programs, they often have more candidates than service options.

When asked to rank the top three challenges to recruitment, respondents placed the following problems highest (in aggregate rank order):

• Volunteer funding

• Length of service (for short and medium as well as long term assignments)

• Family impact and volunteer financial concerns

• Volunteer security

In general, reported attrition rates were very low. Twenty-five of the 28 respondents answering this question said attrition was under 10 percent; confined to one or two instances of early departure; or had no attrition at all. Three organizations reported attrition rates of more than 10 percent. One organization places volunteers without consideration to needed skills; one is largely oriented toward quick disaster response missions; and one provided little host country support for volunteers during the high attrition period.

Principal on-site volunteer concerns were ranked, in aggregate, as follows:

• Feeling isolated

• Health issues

• Safety

• Country politics

• Host culture

• Lack of health infrastructure

• Feeling ineffectual

Combined health and safety concerns far outweigh the other concerns in the list.

The most frequently cited assets and resources for good volunteer performance involved various elements of personal, professional and administrative support for their work, both in country and as a part of international health networks. Specific aspects of these conditions that facilitated volunteer performance include:

• Existence of personal and professional support systems

• Trusted and resourceful local counterparts

• Opportunities to learn from locals

• Long term presence of U.S. organization in country with good local relationships

• Well-defined volunteer responsibilities (especially for short-term volunteers)

• Good peer support and relationships (especially for doctors)

• Basic needs met

The issues of culture shock and culture clash as noted earlier, are particularly complex when dealing with the HIV/AIDS pandemic. Respondents indicated there are several levels to these issues, some of which can be ameliorated through training. As Table D-2 indicates, a majority of respondents provide and recommend some form of U.S.-based cultural training prior to in-country placement. This can range from provision of a manual to the 7-month U.S. and in-country culture and language program required by 3-year volunteers. Organizations that do not provide U.S.-based cultural training often emphasize in-country cultural training. Some organizations refuse applicants with no significant experience living and working in cultures other than their own.

It appears that most organizations do not spend much time discussing differences in medical cultures or indigenous languages. Even when English is the working language, it can be nuanced very differently in another country creating communication barriers.

In summary, volunteers seem to function best when peer support, opportunities for positive interaction with locals and expatriates, and resources for personal, professional, and bureaucratic problem solving are in place.

These responses support observations drawn from discussions of attrition and organizational partnering that point to the successes of well-established partnerships with well defined roles and good supervision as the best contexts for effective volunteer performance. They also suggest that volunteer performance and achievement of objectives are enhanced when health networks have solid and mutually reinforcing relationships at all levels: local, in-country, regional, and international. In this way, local health cultures can be respected and their resources employed to full advantage (for example in organizing traditional birth attendants to support voluntary counseling, testing, and prevention of mother-to-child transmission and in combining HIV work with broader health and development goals). At the same time, volunteers, other expatriate health professionals, and their local counterparts and colleagues can fully utilize resources such as distance learning, international, consulting and sources of information, capacity building, and supply that can be made available through international partnering.