There can be no doubt that there is a need for continuing professional development (CPD) or Continuing Medical Education (CME) in the Ugandan health system. This is not the same thing as saying that Uganda lacks the capacity to train its own health workers. The main need for CMEs and the one that is immediately observed by volunteers when they arrive is that the majority of staff they directly encounter on the wards dealing directly with patients and typically unsupervised are at junior level. Some hospitals depend almost entirely indeed on (unsupervised) student nurses and intern doctors to deliver services.
As we have noted inChapter 2, this does not mean that there are no or
even few very highly skilled and competent clinicians in Uganda but it is rare
tofind them on public wards or supervising/mentoring those staff who are.
During a short (two week) visit, a senior British obstetrician working on one of the busy obstetric theatres in Mulago Hospital expressed dismay at his
initial experience referring to the‘sheer butchery’he had witnessed. It was
only later that he was made aware that all of the doctors in theatre were much junior interns with little experience or supervision. Add to this the over- whelming congestion and sense of chaos made worse by the absence of effective patient management systems (and triage) and it is not surprising that volunteers identify an immediate need for training. And perhaps this
impression–of abject need–and absolute lack of resource–is functional in
terms of attracting AID. On that basis, local managers may hesitate to challenge this naïve prognosis.
This situation has led to an emphasis in health partnership interven- tions on CPD or CME, a term used more commonly in Uganda and
perhaps reflecting once again the dominance of the medical paradigm.
Another factor reinforcing this emphasis on short-course interventions concerns the emphasis within internal (project) evaluation processes on easily obtainable metrics. The following caption frequently displayed by THET to promote the HP scheme indicates the emphasis on training and the challenges of trying to capture more holistic impacts on human resource management systems. The data presented here capture the easiest metrics: numbers of people trained. And measuring this is far easier if staff are taken off the wards and put into rooms where they can be counted. Unfortunately, this tells us nothing about the effectiveness
Having said that, we fully understand the challenges facing organisa- tions like THET under pressure from their own paymasters (DFID) and seeking to justify the expenditure of public funds on development inter- ventions in a time of austerity and swinging cuts in public services. Not
only is this form of AID‘hard to get right’, as Bolton (2007) suggests, but
it is also incredibly difficult to capture. And providing the evidence base
demands highly sophisticated and time-consuming approaches which fail
Fig. 3.1 Numbers of staff trained in the health partnership scheme (Source:
to sit easily alongside the‘smash-and grab’demand for‘objective’(read quantitative) proxy outcome indicators.
The dominant approach to improving care [in low-income coun- tries] (as a result) involves continuing professional development but
(as Byrne-Davis et al. point out),‘little is known about their impact on
practice’(2016: 59). One might argue that the best way to deal with
this situation is not to deploy British professionals as volunteers but to improve local human resource management systems to require senior staff to be present and take on training roles, and for the health system itself to develop CME systems rather than relying on foreign interven- tions. In the capacity-building work we are currently engaged in, in the area of bio-medical engineering aimed at increasing the skills levels of practising technicians, we are beginning to lobby for the development of a CME system and to support the development of its constituent
modules. At present, no such thing is in place.2
However, for the time being, this is the context within which profes- sional volunteers will engage on a day-to-day basis. One might argue that training in itself is innocuous and can only add value. And, the more people we train presumably the more potential there is for positive systems change. One of the SVP volunteers expressed this view in an interview and in response to a question about the role that volunteers could play in system change:
I don’t even know how [a volunteer] would go about [engaging with systems]. There are so many levels of mistrust and corruption. Where to even start to infiltrate the system and go about it in the right way especially if you’re a foreigner trying to come in and introduce policy. It’s not even a can of worms. It’s like a reservoir of snakes. Education is something you can’t take away from someone and so that’s something we can do continually, teach and set an example and then it’s up to that individual if they carry on what you have imparted.
As the respondent notes–this approach is aimed primarily at individual
clinicians and not systems as such. To the extent that a system is the sum of its constituent parts, then training individuals may in the very long term have a systems impact. Or, the individuals could become so demotivated (threatened even) when trying to utilise these skills on an individual basis that they either give up or leave the system.
Certainly it is essential that deploying organisations (including for- eign NGOs) adopt some humility and accept outright that they cannot begin to train all the health workers in Uganda and, as such, this
individual (‘drop-in-the-ocean’) approach is unlikely to generate sys-
tems impact.