Impact case study database

Action-research studies involving the deployment of NHS professionals and undergraduate students (respectively) have informed new, more ethical, models of volunteer and student deployment and the potential for sustainable systems change in LMIC settings. All the work referred to has taken the form of action-research with an explicit focus on multi-level impact grounded in (and assessed through) health systems interventions in Uganda. This includes improvements in the deployment of volunteers, health systems and student placements, as well as influence on policy change in the UK and Uganda:

4.1. Deployment of professional volunteers under the SVP Model

The SVP Model has influenced policy change at a range of levels since 2015: in England, it has shaped the policies of the Global Engagement Directorate at HEE. The Director of Global Engagement confirmed: *‘As a non-Departmental Body of the Department of Health and Social Care, we are heavily reliant, in the development of policy, [on] solid and reliable, evidence-based guidance. Professor Ackers has consistently provided this guidance and as a result has had significant impact on policy in areas such as international ethical recruitment and professional volunteerism’,* further stating: *‘Professor Ackers is an outstanding academic working in a highly relevant field to healthcare policy creation. Her work is a benchmark and reference point to an increasingly large proportion of policy development’ [5.1]. The Tropical Health and Education Trust (THET) further cited the influence of Ackers’ research, stating that it ‘uniquely introduced the concept of ‘co-presence’ into the national vocabulary around volunteering. This has contributed to an important shift in understanding of the role that volunteers can play in health systems change in LMIC settings’ and influenced policy on the ‘ethics of different forms of mobility’ [5.2].

In Scotland, the 2017 ‘Global Citizenship in the Scottish Health Service’ report specifically ‘commends the recommendations of Louise Ackers’ on the importance of aspects of volunteer deployment and risk management as well as advocating adherence to the co-presence principle, with NHS Scotland advised to support global health work which is needs-led and follows these (Ackers’) principles of effective partnership working [5.3 p.62].

Ackers’ research has also influenced policy in the Ministry of Health in Uganda, with the Assistant Commissioner acknowledging her ‘unique approach to complex health system issues’ since 2014 that has *‘ proven to deliver highly sustainable health systems change’ and highlighting the specific value of ‘co-presence’ in preventing systems damage in Uganda [5.4].

In a more immediate sense, the research has been directly applied through one of the major volunteer deployment health partnerships working in Uganda. Knowledge For Change (K4C) is a UK-registered charity, with a Ugandan-registered non-governmental organisation (NGO) which was set up in 2019, focussed on health systems change. K4C has embraced the SVP Model recommended in Ackers’ research [2.1] within its professional volunteering programme and now powerfully advocates for its extension to all UK and international healthcare volunteering programmes [5.5]. K4C has deployed approximately 300 professional volunteers using this approach, many of whom are now back in the NHS [5.5].

The concepts of ‘professional volunteer’ and ‘co-presence’ - both introduced by Ackers - are now prevalent in global health discourse. An example of this is the Manchester-Gulu Health Partnership’s handbook for professional volunteers, developed in April 2017 with Manchester University NHS Foundation Trust, which specifically advocates the principle of co-presence [5.6]. The embedding of this principle into the volunteering culture in Gulu can be seen in a film made by a local Ugandan doctor to improve relationships between professional volunteers and local health workers as part of a volunteer training programme and training materials package provided by the THET in 2020 [5.7]. This resource also includes a film specifically commissioned by THET from K4C as an implementation tool for Ackers’ SVP Model [5.8].

The SVP Model remains unique in challenging the emphasis on medicine in global health and global health volunteering [2.1] and advocates extension of professional volunteering to all NHS cadres.

4.2 Deployment of undergraduates under the EEP Model

The concept of ‘professional volunteer’ has been invoked to differentiate the forms of mobilities of highly skilled professionals from student placements and electives. Ackers’ research on educational placements, funded by HEE, responded to concerns about the potential burden that existing approaches to student electives were placing on already resource-constrained environments and the risks associated with these [2.3]. The research undertaken in 2016 set out the main features of an EEP Model grounded in principles of ‘No Harm’ and optimal and reciprocal benefit.

The generation of evidence-based models of ethical educational placements has directly informed the policies and practices of organisations engaged in the placement of students in medicine, nursing and allied health professions. K4C has actively recruited to the EEP Model, placing approximately 350 students (by December 2020) in Uganda and India from 10 Higher Education Institution partners in the UK, as well as institutions in Germany, Spain, Norway and the Netherlands [5.5]. This Model will be further upscaled to other LMICs over the course of 2021/22, including Cambodia, Vietnam, Nepal, Tanzania, Ghana and the Gambia.

The Overseas Placement Manager at Oslo Metropolitan University, referring to the principles underpinning the EEP electives, confirmed that the University began placing students through K4C ‘ as a direct result of […] the commitment to ethics in student placement processes’ [5.9]. Between September 2016 and February 2019, 38 students were placed in Uganda through this programme (an additional 15 placements were planned for September 2020, but postponed due to the COVID-19 pandemic) [5.9]. The Placement Manager specifically commends the impact that the research has had on their placements policies, emphasising that the organisation has been ‘impressed by the ‘No Harm’ approach’ and confirming that their students have ‘ gained significant and supported exposure to social welfare systems in a Low- and Middle-Income Country setting’ [5.9].

4.3 Impact of the SVP and EEP Models on health systems in Uganda

There is clear evidence of sustained systems change in Ugandan public health services, with both the SVP and EEP Models, deployed in an integrated fashion by K4C, playing a direct and attributable role [5.5]. K4C is actively involved in the strengthening of lower level health facilities to ensure timely and high-quality care. For example, the deployment of the SVP and EEP models in Kagote Health Centre in Western Uganda has resulted in a transformation of services which has been sustained since 2015 [5.4]. Kagote was named by the Ministry of Health as the best functioning Health Centre III in Uganda in 2018. Prior to this, it was an ailing community health facility that had failed to provide the facilities to deliver a baby for over 16 years and yet had a full establishment of health workers [5.4]. Monthly deliveries of babies have since increased from 0 to a sustained average of 40 over 5 years. The Assistant Commissioner of Health Services at Uganda’s Ministry of Health confirmed : ‘The Sustainable Volunteering Model deployed by Ackers is based on a principle of ‘co-presence’ requiring UK volunteers to at all times be working alongside their Ugandan colleagues […] The continued presence of UK volunteers working alongside my health workers has transformed Kagote Health Centre to one of the best performing Community Health Centres in Uganda’ [5.4].

Building on this platform of success, K4C established the first ever see-and-treat cervical screening programme running in a public community health facility in Uganda in 2017 [5.4, 5.10]. The idea came from undergraduate nursing students deployed under the EEP programme and was developed using the SVP Model, with UK midwives working alongside their Ugandan peers for a sustained period of 2 years. Despite initial reluctance, the work has established the principles of co-working and co-presence and reduced absenteeism at the facility [5.4]. K4C subsequently applied to UKAid for a scale-up of this model, founded on SVP principles. Since this time, K4C has trained 30 nurses/midwives; raised awareness of cervical cancer through a major door-to-door programme reaching approximately 3,000 households and screened approximately 1,500 women [5.4, 5.10].

An independent evaluation of this UKAid programme commended the ‘strong delivery of high quality services and establishment of an early sustainability model’ that K4C is in the process of scaling up [5.10]. The key achievements of the project include: exceeding the milestone target for the number of women’s cervical screening by 50%; exceeding the number of health workers trained; benefitting marginalised women in particular beyond the life of the project; demonstrating a strong capacity-building approach for project staff and strengthening on-the-ground training in project districts [5.10].