the international health links manual

The Tropical Healthand Education Trust

The InternationalHealth LinksManual

A guide to starting upandmaintaining long-terminternational healthpartnerships

Maïa Gedde

Second Edition

This Links Manual has beenproduced by the Tropical Healthand Education Trust (THET) andthe views expressed in the LinksManual are those of THET andTHET alone. Copyright in the LinksManual is THET's and anyreproduction of any part of theLinks Manual must acknowledgeTHET's copyright.

The UK Department forInternational Development gavefinancial help for the productionof the Links Manual, but bears noresponsibility for the viewsexpressed in it.

As a charity seeking to spend allits funds on the long-term relief ofsuffering, THET cannot accept anyliability in respect of any use ofthis Manual.

Copyright © THET 2009

ISBN: 978-0-9560942-1-6

Written and edited by:Maïa Gedde, THET

Final edit:Ellen de Vries, The Copy House

Designed by:Karen Hall, Clear Design (Scotland)

Photography:Lihee Avidan, MonkeywitchJohn MacDermot, THETHannah Maule-ffinch

Front cover photograph:Nottingham-Jimma Link

Printed and bound inGreat Britain by:CPI Antony Rowe,Chippenham and Eastbourne

The InternationalHealth LinksManualA guide to starting upandmaintaining long-term internationalhealth partnerships

Acknowledgements:

I am grateful to all those whocontributed with case studiesand examples, acknowledgedfor their individual contributionsthroughout the Manual. Thecomments from various reviewerswere invaluable in shaping thisresource and special thanks go to:Dave Baillie; Collette Dean(British Council); Susana Edjang;Hilary Fenton-Harris;Penny Humphris; Francis Gondwe(CHAM, Malawi); Biku Gosh;Ian Holtby; David Hope-Jones(Scotland Malawi Partnership);Richard Kennedy; Chris Lavy;Douglas Lungu, Nick Maurice(BUILD); Themba Mhango;Agatha Nambuya; Elizabeth Ollier;Eldryd Parry; David Percy;Raúl Pardíñaz-Solís (Skillshare);Linda Turner; Jude Rawley;Morag Reynolds; Tessa Richards(BMJ); Sally Venn;Myles Wickstead; Jerome Wright;Marcia Zondervan (Vision 2020)in addition to all of THET staff,advisors (Jean Bailey, Bob Lane,Tom Lissauer, Pam Walter), and inparticular Andrew Purkis forediting numerous drafts. I am alsoindebted to Rosa and Mike Lewisfor providing Candelariotranquillity.

Abbreviations 6

Foreword 7

About the Manual 8

SECTION 1. Overview of International Health Links 12

1.1 An introduction to Links 14

1.2 Why Link? 20

SECTION 2. The Practicalities of a Link – from start to finish 26

2.1 Thinking about a Link? 28

2.2 Jointly planning the Link 40

2.3 Coordinating the Link 50

2.4 Visits to the Developing Country organisation 58

2.5 Visits to the UK organisation 76

2.6 Building on the work of exchange visits 86

2.7 Managing change 92

2.8 Scaling up the work of the Link 100

2.9 Funding a Link 106

2.10 Ending a Link 114

2.11 Limiting and avoiding risk 118

SECTION 3. Appendices 126

1

Contentsat a glance

Abbreviations 6

Foreword 7

About the Manual 8The context 9Who should read this Manual? 9How to use this Manual 9Terminology 10Tell us what you think 10

SECTION 1. Overview of International Health Links 12

1.1 An introduction to Links 14What is a Link? 15A short history of Links 15Underpinning principles of Links 17Different models of Links 17

1.2 Why Link? 20Who benefits? 21What can Links do? 22Examples of how and what Links can support 23

SECTION 2. Practicalities of a Link – from start to finish 26

2.1 Thinking about a Link? 28Initiating a Link 29Step 1: Establish a group of interested people 29Step 2: Understand the implications of your commitment 30Step 3: Is a Link right for your organisation? 31Step 4: Determining the aims of the Link 34Step 5: Finding a partner 35Step 6: Get agreement and support from your management 37What’s next? 38

2.2 Jointly planning the Link 40The basics of planning 41Stage 1: Preparing for a joint planning process 41Stage 2: Identifying priority areas 44Stage 3: Setting (SMART) Objectives 46Stage 4: Planning activities 48Stage 5: Monitoring objectives and activities 49

2.3 Coordinating the Link 50Establishing a Link Committee 51Communication 52Record keeping 54The Link induction pack 54Developing a Memorandum of Understanding (MoU) 55Registering as a UK charity 55Managing and transferring funds 55

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Table ofContents

2.4 Visits to the Developing Country organisation 58Who should be involved? 59Visit duration and time off 61Preparation for the visit 62Practical information for visits and Link induction pack 64Dos and don’ts overseas 70Follow-up after visits 72

2.5 Visits to the UK organisation 76When are visits to the UK a good idea? 77Who should be involved? 78Visit duration and time off 78Preparation for the visit 80Practical information and Link Induction Pack 81Dos and don’ts in the UK 84Follow-up after visits 84

2.6 Building on the work of exchange visits 86Mentoring and support 87Equipment and book donations 87Monitoring and evaluation (M&E) 89Joint research; disseminating and publishing your work 89

2.7 Managing change 92Barriers preventing change 93Supporting change 95

2.8 Scaling up the work of the Link 100What is meant by ‘scaling up’? 101Why scale up? 101When is the right time? 102How can it be done? 102

2.9 Funding a Link 106Developing a fundraising strategy 107How much money do we need? 108Who will coordinate fundraising and how? 109What are the funding sources available? 110

2.10 Ending a Link 114Six reasons for Link inactivity (and how these can be avoided) 115Ending a Link (but maintaining a good relationship) 117

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Table ofContents

2.11 Limiting and avoiding risk 118Why do Links need to do a risk assessment? 119How to do a risk assessment? 119Risk management documents 122Insurance as a way to mitigate risk 122Professional liability, indemnity and registration 123Briefing 124

SECTION 3 : Appendices 126

Appendix 1: About THET 128Appendix 2: The NHS 129Appendix 3: Other organisations supporting Links 130Appendix 4: Sample paper to the Board 132Appendix 5: The health context 134Appendix 6: Template Memorandum of Understanding (MoU)

for a Link 138Appendix 7: Links report template 142Appendix 8: Resources in health information 144Appendix 9: Sample donor mapping excercise 146

4

Table ofContents

5

Text Boxes

Partnerships and international development 18Personal, professional and organisational rationale for Links (UK perspective) 21Factors affecting health systems (and where Links can play a role) 22Potential areas that Links can support 24Decision tree: is a Link right for your organisation? 31The resources needed to run a Link 34Carrying out a consultative needs assessment within your organisation 35Criteria for selecting a Link partner 36Making a case for a Link to your Board 38Aims, objectives, outcomes, outputs and activities 41Prioritising Link objectives 45Defining SMART objectives for your Link 47Sample activity plan 48Means of communication with your Link partner 52Transferring funds to the DC partner 56Planning checklist for visit to the DC organisation 62Information and tips when travelling to the DC 64Dos and don’ts in the DC 70Planning checklist for visits to the UK organisation 80Information and tips when travelling to the UK 81Dos and don’ts in the UK 84Equipment and book donations 88THET’s M&E Toolkit 89Addressing the barriers that prevent change from happening 94Examples where learning was put into practice 96Examples where learning was not put into practice 97Health system strengthening 101Examples where Links have scaled up their work 103Log frames 104Benefactor versus collaborating partners 107Tips when costing activities 108Sample budget and fundraising plan 109Duties of a fundraiser or fundraising team 110Sources of funding for Links 111Reasons for Link inactivity 115Five steps to conducting a risk assessment 121Professional liability, indemnity and registration 123Organisations providing specialist support to Links 130Non-UK umbrella organisations 131A contextual comparison of health care 135

Please note: This list only includes the principal text boxes of the Manual

A&E Accident and Emergency

BIBA British Insurance Brokers Association

CIA Central Intelligence Agency

CPD Continuing Professional Development

DC Developing Country

DFID Department for International Development (UK)

DH District Hospital

DoH Department of Health (UK)

EU European Union

FCO Foreign and Commonwealth Office (UK)

GAVI Global Alliance for Vaccines and Immunisation

GDP Gross Domestic Product

GMC General Medical Council

GTZ German Technical Cooperation

GP General Practitioner (UK)

HIFA2015 Healthcare Information for All by 2015

HSSP Health Sector Strategic Plan

IMF International Monetary Fund

ITLS International Trauma Life Support (course)

JICA Japan International Cooperation Agency

KCMC Kilimanjaro Christian Medical Centre

M&E Monitoring and Evaluation

MoH Ministry of Health

MoU Memorandum of Understanding

NGO Non Governmental Organisation

NHS National Health Service (UK)

NMC Nurses and Midwives Council

ODA Official Development Assistance

PCT Primary Care Trust (UK)

PHI Partnerships in Health Information

PEPFAR President’s Emergency Plan for AIDS Relief (US)

RTAs Road Traffic Accidents

SAPs Structural Adjustment Policies

SHA Strategic Health Authority (UK)

SMART Specific, Measurable, Achievable, Relevant and Time-Bound

SWAp Health Sector Wide Approach

THET Tropical Health and Education Trust

UK United Kingdom (formed of England, Scotland,Wales and Northern Ireland)

VSO Voluntary Services Overseas

WHO World Health Organisation

6

Abbreviations

This Links Manual is a fundamental resource for a Links movement that hasgrown markedly and been developed carefully over the last three years.Links are long term partnerships between UK health sector organisationsand counterparts in the developing world.

THET produced the first Links Manual in 2005, and it has proved to bea useful and reliable guide for many organisations that have started ordeveloped a Link.

THET was funded by the Department for International Development (DFID)and the Department of Health to support Links in the three years from2005. Since then the number of organisational Links on THET’s databasehas grown from just over 20 to 100. Links have been encouraged to sharegood practice and learning with the wider Links movement, so that wheelsdo not have to be re-invented and all Links can strive to achieve their best.Thus, strong efforts have been made to help improve quality and impact, aswell as quantity. This revised Links Manual is a key product of this process.

The 2005 Manual was targeted at UK NHS organisations. This one isintended equally for the developing country partners. It better embodiesone of the core values of Links: they respond to the priorities ofdeveloping country partners and are led by them. There is also greaterrecognition that although the NHS accounts for most UK Links partners,there are also UK partners drawn from university health faculties and otherprofessional bodies and networks. There is more attention on how a smallLink can develop more strategic ambitions, and to the sensible risk andsecurity precautions that Links should consider. More generally, the newversion embodies three more years of widening and deepening experience.

This is not a static product. Learning by Links continues, and the format ofthe Manual allows it to be updated and amended in the light of experience.We encourage all its users to let THET know of anything that may need tobe added, subtracted or amended as they learn from their Links work.

We are grateful to DFID for its funding for this Manual, to Maïa Gedde forpulling it together, and above all to all those Links participants who sharedtheir experiences and responded to our consultations. They have therebyenabled more of their colleagues across continents to help build health carecapacity in the developing world – and enrich the UK sector too.

Stephen Tomlinson, CBE

Chairman, Tropical Health and Education Trust (THET).March, 2009.

7

Foreword

In this Chapter:• The context

• Who should readthis Manual?

• How to use thisManual

• Terminology

• Tell us what youthink

This comprehensive and detailedLinks Manual is aimed at both UKand Developing Country Linkpartners.

It has been developed tofacilitate the work of Links,encouraging them to reflect ontheir work and becomemorestrategic.

Its length should not be daunting.Section 1 provides an overview ofLinks, while Section 2 should beused as a reference document,providing advice for Links atdifferent stages of theirdevelopment.

8

About theManual

1 Links Manual: A guide to starting up and maintaining long term health partnerships. THET 2005

9

About theManual

The contextLinks partnerships have thecapacity to make a significantcontribution to health systemstrengthening but only if they arewell planned, managed and alignedto needs. This Manual, now in itssecond edition, provides guidance,shares experiences and offersexamples of good practice fromthose directly involved in Links.

Its aim is to help those engaged ina Link to think more strategicallyabout their work.

Both partners in the UK and indeveloping countries shareresponsibility for the effectivenessof the Link. They need to jointlyagree the priorities and directionof the Link within a framework andrecognise the benefits toprofessionals and organisationsinvolved at both ends of thepartnerships.

Governments and HealthManagers in the UK, Ghana,Uganda, Malawi, Zambia, Ethiopia,Tanzania, Somaliland and Nepal,amongst others, are nowbeginning to look more actively athow these types of partnershipscan contribute to health systemdevelopment in their countries.

In March 2005 THET launched thefirst Links Manual1 at the LinksConference in Leeds. This broughttogether THET’s experience overten years of working through Linksto improve health in Africa anddrew on examples from elevenLinks. Since 2005 THET hasreceived support from the BritishGovernment (through DoH andDFID) to support the work of Links.

By September 2008 THET’s LinksSearch database featured 99 Linksbetween UK and DevelopingCountry health organisations, andboth the Welsh Assembly and theScottish Government supportedLinks within their countries. Thisstriking growth is perhaps partlydue to the first Links Manual andTHET’s wider advocacy efforts.This comprehensive Manualrepresents the accumulatedlearning from THET’s andindividual Links’ experience.

Who should read this Manual?What are Health Links? How mightour organisation benefit from aHealth Link? What can a Link helpus to achieve? How can we run aLink effectively and ensure it hasan impact on health care?

If you are interested in theanswers to any of these questions,this Manual is for you.

As a reference document for LinkPartnerships, this Manual is aimedat those seeking to form a Link, oralready involved in an establishedLink. Those who may be interestedin reading it include:

• Health professionals, includingnurses, clinicians, therapists,researchers, teachers,managers or support staff fromhospitals and trainingorganisations (medical andnursing training schools) in aDeveloping Country and the UKwho are involved in a Link orseeking to form a Link.

• Policy makers, health advisors,NGOs and others from the UKor a Developing Countryinterested in finding out moreabout what Links are and whatthey can offer.

While many of the issues will besimilar for both the UK and theDeveloping Country partners,aspects of these may be morerelevant to one or the otherpartner. Colour coding has beenused throughout the Manual tohighlight those most relevant toeach:

green for the UK andyellow for the DevelopingCountry (DC) partner.

How to use this ManualYou may wish to read this Manualfrom cover to cover, but equally itcan form a useful resource fordipping into at any time as youcome across new issues.

SECTION 1: Is a generalintroduction to Links for thosenew to the concept of LinkPartnerships.

SECTION 2: Is the substanceof the Manual and addressesdifferent stages of a Link fromestablishing a Link through toscaling up its work and when toend it.

SECTION 3: Are the appendicesreferred to in other sections ofthe Manual.

The Manual does not profess toprovide a blueprint for a successfulLink. Instead it shares theexperience of THET and Links tohighlight key issues and stimulateideas.

DC

UK

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10

About theManual

TerminologyInternational Health Links isused interchangeably with Linksthroughout this Manual.

Links should not be confused withthe other NHS usage of this term,referring to liaisons with localauthorities. For a full explanationof what International Health Linksare in the context of this Manual,refer to Chapter 1.1.

In the absence of betterterminology we have opted to usethe abbreviation DC (developingcountry) to describe countrieswith a low Human DevelopmentIndex ranking, where the healthproblems are magnified by theshortage of health workers,population growth, conflict,and lack of resources andinfrastructure. Many suchcountries are in Sub Sahara Africaand Asia. Throughout this Manualwe refer to DC and UKorganisations forming Linkpartnerships.

SymbolsCASE STUDY –real examples fromother Links

EXAMPLE –hypothetical exampleto explain key ideas

REMEMBER –highlights importantideas

GOOD PRACTICE –sharing advice

KEY TERMS –provides a definition of theterms used in the text

DID YOU KNOW? –interesting facts andinformation

FIND OUT MORE –references to books,internet sites, and journalsthat may provide moreinformation

UK – information which isspecifically relevant to theUK partner

DC – information which isspecifically relevant to theDC partner

CHAPTER CHECKLIST– these provide a summaryof the main points and canbe found at the end ofeach chapter

Tell us what you thinkThe context of international healthis changing rapidly, and goodpractice in International HealthLinks is developing all the time.THET will therefore aim to produceupdated versions of the Manual.If you have any comments youwould like to share, areas that youhave found particularly useful,sections you don’t agree with,advice of your own, or case studiesyou think others may find useful,please tell us!

Please e-mail your comments [email protected]

This Manual providesguidance, shares experiencesand offers examples of goodpractice from those directlyinvolved in Links.

Chapter 1.1 An introduction to Links,the philosophy on which they arebased and the political context withinwhich Links work.

Chapter 1.2 Who benefits from Links,how the work of Links contributes toHealth System strengthening andwhat types of work Links have beenengaged in.

12

SECTION 1.Overview of InternationalHealth Links.

In this Chapter:• What is a Link?

• A short historyof Links

• Underpinningprinciples of Links

• Different modelsof Links

An International Health Link(a Link) is a partnership between aUK and a Developing Country (DC)health organisation. This Chapterhelps you to gain an understandingof what Links are, what theirpurpose is and the principles onwhich they are based.

14

1.1 An introductionto Links

2Links may be of different scales and sizes and many develop from smaller partnerships and personal collaborations.Health Links are one of many types of organisational Links between UK and DCs. An increasing number ofcommunities, schools, faith-based organisations, local authorities, youth groups and others in the UK have establishedpartnerships with counterparts in DCs. Health Links may fit in within a wider community Link. Such Links often involvethe diaspora in the UK from the countries with which they are linked thus adding to greater social cohesion. Differentkinds of Links come together in the UK under the umbrella of the organisation BUILD. (www.build-online.org.uk)

3The partners involved at the UK end may be NHS Trusts, Foundation Trusts, Primary Care Trusts (PCTs), GP practices,Universities, professional bodies, clinical networks, etc. At the DC end, partners may be hospitals, health centres,District Health Offices, training schools, universities, professional bodies, etc. If necessary, Links may also be formedbetween more than two partner organisations.

1.1

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What is a Link?Links are all about peopleworking together to share ideas,knowledge and friendship toimprove health care. By doingthis within an organisationalagreement, Links have thepotential to be strategic and longterm, better able to inspirechange. Some established Linkshave shown that they are ableto bring about importantimprovements in health care.

A Link2 is a formalised voluntarypartnership between counterparthealth organisations3 in the UKand a Developing Country (DC).The primary purpose of Links isto build the capacity of the DCorganisation, but there are alsoimportant secondary benefits forthe UK health sector. The activitiesthat Links support can be verybroad and range from trainingand capacity-building for staff,providing practical skills,continuing professionaldevelopment, supportingimprovements within DCorganisations, facilitating research,and curriculum development etc.

Who gains? A well-managed Linkcan bring about importantchanges for both the DC and theUK organisation. DCs can buildcapacity and motivate their staffby drawing on the UK partner’sexpertise and technical assistance,according to their own priorities.

The UK organisation also hasa great deal to gain; it has theopportunity to develop its staff,it gives them ideas for serviceimprovements and exposes themto international health issues.It is also an opportunity for bothorganisations to engage in jointresearch.

In an ideal Link, both organisationswill benefit greatly in differentways. The main currency of theLink is the professional expertiseand human resources availablewithin both organisations.

How does it work? After initialset-up and joint planning, the workof a Link typically involves some ofthe following activities:

• Reciprocal visits to deliveragreed training

• Support through mentoring,equipment and trainingmaterials

• Technical assistance on thedevelopment of services

• Monitoring and evaluating thework to plan future activitiesand scale up support

A short history of LinksThe wider political agendaWhile THET has been supportingand working with Health Links forover ten years, it is only since2004 that Health Links have beenon the wider political agenda.

The Commission for Africa (2004)and the Gleneagles G8 Summit(2005) put health and health carein Africa at the centre of theiragenda. The WHO report, HumanResources for Health (2006) tooka lead in highlighting the severeshortage of human resources forhealth in developing countries,bringing to the fore many of theissues that had confronted thoseworking in the health sector indeveloping countries.

DC Governments are increasinglyseeing Links as an opportunity totap in to the expertise availablewithin the UK. Many doctors fromDCs have completed some part oftheir medical training in the UKand look to the UK for guidanceand support. THET has developedcodes of conduct and Memorandaof Understanding (MoU) with theMoH of Uganda and Ghana, amongothers. The many diasporacommunities in UK also make animportant contribution tosupporting the development oftheir own countries and this canbe enhanced by Health Links.

DID YOU KNOW?

There is a direct relationshipbetween the ratio of healthworkers to population andthe survival of women duringchildbirth and children ininfancy. As the number ofhealth workers declines,survival declinesproportionately. If donorfunds are to have any impactand the MillenniumDevelopment Goals are to beachieved, the right number ofhealth workers with the rightskills need to be in place.

The 2006 WHO report statedthat 57 countries, most ofthem in Africa and Asia,faced a severe workforcecrisis, with Sub-SaharanAfrica facing the greatestchallenges. Africa has 11% ofthe world’s population, 24%of the global disease burdenand only 3% of the healthworkers to deal with it. Evenwithin countries inequalitiesexist, with rural areas findingit harder to attract healthworkers than the urbancentres.

Working together for Health,WHO report 2006

2005THET published the first LinksManual which raised awarenessaround what health partnershipscould offer. THET’s role insupporting Links was furtherencouraged with a staffsecondment from the Departmentof Health (2005-2007) andfunding from the Departmentof Health and Department forInternational Development.

It was becoming increasingly clearthat it was not possible to deliverthe Millennium Development Goals– the bedrock of internationaldevelopment policy aims – withouta significant increase in capacity,skills and training in thedeveloping countries; all areas inwhich Links can play an importantrole.

2006Since 2006 the devolvedGovernments of Scotland andWales have also been increasinglysupportive of international health.The Wales for Africa Group, whichreceives funding from the WelshAssembly Government, has beensupporting Links since 2006 andstrongly believes that sharingskills, experiences and resourceshelps communities in Africa andWales. The Scottish Governmentincludes support for Links as partof its agreements with AfricanGovernments including Malawiand Zambia to help improvehealth care.

2007/2008The UK Government respondedpositively to the Crisp Report(2007) which looked at how UKhealth expertise could be used tohelp improve health in developingcountries. It championed the roleof International Health Links andof THET. The Government agreedto support the development ofLinks via a new grants schemeand information centre relatingto Links. It agreed to pay pensioncontributions to those doinghealth work overseas for extendedperiods of time. Links were alsofeatured favourably in theGovernment’s wider Global HealthStrategy, “Health is Global”(September 2008).

FIND OUT MORE

• About THET – Appendix 1

• Our Common Interest,report published by theCommission for Africa(2005)

• Working together forHealth, WHO report 2006,available from www.who.int

• Global Health Partnerships,Lord Crisp (2007)Significant referenceto THET is made

• Government response tothe Crisp report (2008)

• Health is Global: A UKGovernment Strategy2008-13, Departmentof Health (2008)

KEY TERMS

Millennium DevelopmentGoals (MDGs): are a set ofgoals to be achieved by 2015that respond to the world'smain developmentchallenges. The MDGs aredrawn from the actions andtargets contained in theMillennium Declaration thatwas adopted by 189 nationsand signed by 147 heads ofstate and governmentsduring the UN MillenniumSummit in September 2000.


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Underpinning principlesof LinksTHET advocates a set of principlesto underpin the work of Links,which may differentiate themfrom other types of twinningarrangements or aid initiatives.The underpinning principles are:

• The primary focus of Links ison capacity-building and staffdevelopment through targetedtraining. While occasionallyLinks may provide additionalsupport, such as equipment,books or direct service delivery,this is not their primary remit.

• Links specifically respond tothe requests (explored throughcareful dialogue) and worktowards the goals of theorganisation in the DC withina partnership.

• Links are organisationallysupported, or formalisedthrough a network, enablingthem to be interprofessional,plan for the long term, workmore effectively and be lessvulnerable to staff turnover.While individuals play animportant role, a Link is acollective effort.

• Links are interprofessional andusually interdisciplinary, andable to draw on a range ofexpertise from the UK partnerorganisations. This allows theLink to be flexible and respondto changing priorities of the DCLink partner.

• Links are long term.‘Strengthening health systems’is a long term goal and changeis often slow. Links take time todevelop, are based on trust andunderstanding and should be an

enduring collaboration betweenpartners, not limited to shortterm gains.

• The work of Links is alignedwith national strategies andorganisational priorities anddoes not aim to create parallelsystems or services.

• Links are a means to an end(strengthening alreadyestablished health systems),rather than an end inthemselves. The added valueof a Link should regularly bereviewed through evaluation.

REMEMBER

The UK partner muststart with the question: Whatare your priorities and whatdo you want us to do? And,having explored this in acareful dialogue, draw onexpertise from across theirorganisation to be able torespond to this need.

Different models of LinksThere is no pre-defined modelfor a Link, as each one may differslightly. What they are trying toachieve and who is engaged mayalso vary from Link to Link.

A simple Link will be a partner-to-partner relationship. Theseusually work best if they arebetween similar organisations.The partners may be health careproviders such as hospitals,primary health care providers,health training schools ornetworks of professionals.

In some cases the Link maybe more complex: a core Linkdrawing on support from other

organisations or a recognisedtripartite relationship. Whetherthe partners are a singleorganisation or a more complexcoalition, Links should arisethrough a specific need or requestfrom the DC, and be matched to aUK organisation with a similaroutlook.

CHAPTER CHECKLIST

} Links are partnershipsbetween UK and DCorganisations with theprimary aims of sharingknowledge andinformation to improvehealth services.

} Links have recentlygained momentum andincreasing governmentsupport.

} To be effective a Linkmust be well planned andbe underpinned by anumber of key principlesincluding a focus onbuilding capacity, beingresponsive andmultidisciplinary.


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18

DID YOU KNOW?

Partnerships and International Development

Health Links are one element of international development partnerships; others include schooltwinning arrangements, higher education and science/technology partnerships. They are generallyset up in recognition that there are mutual benefits to both sides of the Link or partnership.

The history of international development has not always been characterised by such balance.Indeed, many of the terms traditionally used to describe relations between two parties reinforcethe imbalance – ‘donors’ and ‘recipients’, for example. ‘Aid’ suggests a one-way relationship, andis now normally used only in the context of humanitarian or emergency assistance. ‘Officialdevelopment assistance’ is standard terminology; ‘economic co-operation’ is also used.

International development as we understand it really began in the late 1950s, as the colonialpowers provided financial and technical support to their former colonies as they gainedindependence. Much of this was used to maintain the organisations set up during the colonialperiod – schools, hospitals and roads. This ‘capital aid’ was part of a package which includedtechnical assistance, and in the 1960s and 1970s favoured the provision of personnel from the UK(judges, doctors, teachers etc.) as local capacity was being developed.

While there was some effort made in the 1970s and 1980s to ensure that ODA supported thedevelopment of livelihoods and a better quality of life for ordinary people (see, for example, the1973 Government White Paper ‘More Help for the Poorest’), international relations – including aidand trade – were largely driven by the dynamics of the Cold War. The over-riding consideration fordonors was not about recipient Government efforts to reduce poverty, but on which side of theideological divide they stood.

This largely changed with the fall of the Berlin Wall. European countries in the former EasternBloc were told that they would be welcome in the European Union, but only on condition that theycarried out political and economic reforms which would lead to them becoming more open andpluralistic societies. In the early 1990s, these considerations were increasingly applied also torelationships with developing countries, with support increasingly dependent on their record onissues like governance, human rights and social inclusion.

At the same time, there was an increasing recognition that development assistance should supportpolicies and programmes developed in-country, rather than seek to drive them. The late 1990s sawthe development of ‘Poverty Reduction Strategy Papers’ produced (in theory, and increasingly inpractice) in developing countries. The willingness of the international community to supportcountry-driven programmes has been accompanied – at least for those developing countriesjudged to have sound policies – by a continuing shift away from project assistance towards sector-wide approaches and general budget support.

In September 2000, 147 Heads of Government signed up to the Millennium Development Goalsin New York. They were aspirational and non-ideological, with a strong focus on basic health andprimary education outcomes. But it has become increasingly clear, as highlighted in the 2005Commission for Africa Report, ‘Our Common Interest’, that it will not be possible to deliver thoseoutcomes by 2015 without a significant increase in capacity, skills and training.

Links can play an important role in the development of organisational capacity and the building ofhealth and education systems in developing countries; and at the same time, as everyone involvedin a Link will attest, the learning is very much of mutual benefit. Health Links are a manifestationof true partnership – a partnership from which everyone gains and in the process makes the world,in however small a way, a better place.

Photograph (right): Hannah Maule-ffinch, Uganda

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Links can play an importantrole in the development oforganisational capacity and thebuilding of health and educationsystems in developing countries.

1.2Why Link?

20

This Chapter looks at who benefitsfrom Links, what support Linkshave given and asks whether Linksreally have an impact.

The primary objective of the Linkshould be to improve healthservices for the poorest people indeveloping countries, but both UKand DC organisations involved inLinks often report significantbenefits.

In this Chapter:• Who benefits?

• What can Links do?

• Examples of howLinks can work

1.2Why Link?

21

Who benefits?

“You are making anapparent difference in ourhealth care delivery at thereferral hospital. Thank youall members of theSouthern Ethiopia GwentHealth Link”

Dr Yifru, HawassaUniversity, Health SciencesCollege, Ethiopia

If a Link is well planned andmanaged, it can bring aboutimportant changes for theindividuals involved in the Link,the organisations within whichthey work, and ultimately thepatients that they serve. ManyLinks report significant benefitsand improvements in services.At the moment much of this isbased on anecdotal reports, butas Links start to integrate morerigorous evaluation into theirwork, the evidence base willbecome stronger and moreclearly documented.

The following table is based onone piece of research carried outby King's College Hospital whichlooked at the benefits to the UKorganisation of being involved ina Link.

Main benefits for the NHS

Personal

• Personal satisfaction/inspiration

• Learning about differentcultures

• Appreciation of NHS/senseof perspective

Professional

• Understanding of patients fromrelevant part of the world

• Hones clinical skills, andrefreshes basic skills withoutdependence on high-techmachinery

• Familiarisation with pathologiesthat are less common in UK(but may grow there)

Non-Clinical professional skills

• Improved teaching skills

• Development of resourcefulness

• Greater awareness of how toavoid waste and work with fewresources

• Team skills enhanced byinterdisciplinary team effort

Organisational

• Link can enhance reputation

• Good for job satisfaction,retention and motivation ofcommitted staff

• Good for recruitment ofcommitted NHS staff

Universities

• Can assist global cachet

• Good framework for studentelectives

• Helps recruit committedstudents

Personal, professional and organisational rationale for Links(UK persepective)

Disadvantages for the NHS

• Risk of exhaustion, stress,from overseas Link activity

• Neglect of family whileengaged in Link work on topof normal demands

• Some annual leave used up ifno study leave allowed. Higherrisk of accident or securityproblem in some cases

• Problems of arranging coverand imposing on others whenabsent on Link business

• Finding alternative cover whenpeople are away onLink business

• Opportunity costs; time andresources expended on Linksare not available at the sametime for other expressions ofCorporate Responsibility ororganisational improvement

• Need to manage security risks

• Distraction from financialimperatives of the ResearchAssessment Exercise

1.1

What can Links do?

Can Links contribute to healthsystem strengthening in DCs?

The effectiveness of any healthsystem is determined by theinteraction of many influencingfactors and Links can contributeto some of these influentialfactors. If the Link is well plannedand responds to specific needs,

this contribution will be importantbut is likely to be modest.

The resources available to mostLinks are very small whencompared to the large budgetsavailable to other global initiativesand international partnershipssuch as GAVI, PEPFAR and UNICEF.The range of expertise available ina UK organisation will be wide, but

the time available to contributewill be limited for most people.

The following diagram illustratessome of the factors which are atplay in determining how well ahealth system functions; thearrows illustrate some of the areaswhere Links have shown they canplay a role.

1.2Why Link?

22

HealthWorkforcenumbersskillbase

&motivation

r

Public Healthand diseaseprevention

Managementand

InformationSystems

FactorsaffectingHealthSystems

Leadership andGovernancewith strategic

policyframeworks

Health Financing% of GDPto health &

donor support

DiseasePrevalence

Acute/chronic

Medical productsDrug availabilityand distribition

systems

Infastructurebuildings,

equipment, accessto services

Socio-economicfactors

education,nutrition,

employment

r

r rr

r

r

Factors affecting Health Systems(and where Links can play a role)

UK Link partners need to be awareof the many different factors atplay. There is sometimes anidealistic notion among those newto international work that there isa quick and easy solution and theLink alone will be able to turnthings around.

This is unlikely to happen and mayresult in a loss of enthusiasm whenchange is slow to happen. The Linkcan provide an importantcontribution but this will mostoften be the case when the otherfactors at play are also conduciveto this change. On the other hand,persistence and sounddevelopment of the Link can payoff to the point that, in somecases, the Link eventuallybecomes a vehicle for moreextensive programmes of workbacked by funding agencies.

REMEMBER!

Change is about evolutionnot revolution. There issometimes an unrealisticnotion amongst those new tointernational work that thereis a quick and easy solution.In reality change is slow tohappen. See the case studyon p30.

Examples of what Links cansupportLinks have been involved in anextremely broad range of issues.Much of the work of Links fallsunder the category of capacity-building: developing the skills ofhealth workers, organisationalstructures, resources andenthusiasm of overseas colleaguesto improve health services. Thissection gives some examples ofsome of the things that Links havebeen asked to support.

FIND OUT MORE

For examples of what Linkshave supported refer to theexamples on THET's website.

CHAPTER CHECKLIST

} If well planned, Links areable to bring aboutimportant benefits to bothUK and DC partners. It isimportant for Links tothoroughly documentthese impacts.

} While the contributionthat Links can make toimproving health servicesis only modest, thepartnership nature of thework makes it valuable.

} Links are able to supporta variety of differentareas, many of whichcome under the broadheading of capacity-building. Links shouldalways respond to theexpressed needs of theDC partner.

1.2Why Link?

23

/

!

}

1.2

1.2Why Link?

24

Potential areas that Links can support

Training thetrainers

Undergrad/Postgradtraining

Introducingnew

technology

Developmentof systems

and protocols

Curriculumdevelopment

Potentialareas thatLinks cansupport

ContinuingProfessionalDevelopmentand in-service

training

Strengtheningexistingservices

Distancelearning

Equipmentprovision

Collaborativeresearchincluding

clinical auditthrough active communication

between partners

Photograph (right): Lihee Avidan, Malawi

Change is about evolutionnot revolution. Links arelong-term partnerships.

This section looks at the details ofworking in a Link. It takes you through allthe stages from finding a partner, toplanning visits, developing your workand when to end a Link.

Chapter 2.1 Thinking about a Link helpsyou think about whether a Link is right foryour organisation and takes you throughthe initial steps of establishing a Link.

Chapter 2.2 Jointly planning the Linksuggests how this can be done, whoshould be involved and what the mainissues are.

Chapter 2.3 Coordinating the Linkconsiders the important elements ofhaving an effective Link Committee ineach partner organisation to establishgood coordination, charity registrationand fund management.

Chapter 2.4 Visits to the DCorganisation talks you through some ofthe logistical issues when planning visitsfrom the UK to the Developing Country(DC) organisation.

26

SECTION2.Practicalities of a Link– from start to finish

Chapter 2.5 Visits to the UKorganisation addresses issues for thoseplanning and undertaking visits to the UKand covers issues relevant to both the UKand DC organisation.

Chapter 2.6 Building on the work ofvisits provides guidance on the issues ofmentoring, equipment provision andsupport to keep the momentum going.

Chapter 2.7 Managing change highlightsissues to be aware of when promotingchange as part of the Link.

Chapter 2.8 Scaling up the work of theLink helps you to think about broadeningyour work to increase its impact.

Chapter 2.9 Funding a Link gives ideasand information about developing afunding strategy and targeting funders.

Chapter 2.10 Ending a Link looks atsome of the reasons why a Link maybecome defunct and how these situationscan be avoided.

Chapter 2.11 Limiting and avoiding riskintroduces the subject of risk and duediligence.

27

In this Chapter:• Initiating a Link

• Is a Link right foryour organisation?

• A step by stepguide:

Step 1: Establish agroup of interestedpeople

Step 2: Understandthe implications ofyour commitment

Step 3: Is a Linkright for yourorganisation?

Step 4:Determining theaims of the Link

Step 5: Find asuitable Linkpartner

Step 6: Getagreement andsupport from yourmanagement

• What’s next?

Links have the potential to make avaluable long-term impact onhealth care; but to do so they haveto be based on a genuine need,have long-term commitment fromtheir organisations and be built onsolid foundations. This Chapterhelps you think about whether aLink is right for your organisationand takes you through the initialsteps of establishing a Link.

28

2.1 Thinkingabout a Link?

Colour coding has beenused throughout theManual to highlight thesections which are mostrelevant to each:

green for the UKand yellow for theDeveloping Country(DC) partner.

2.1

29


Initiating a LinkThe initial drive to get involvedin a Link may come from anyindividual or group of peoplewithin an organisation. Perhapsyou have read about Links in anarticle or heard about them at aconference, from a colleague orperhaps you have beenapproached by a potential partnerorganisation. You may think a Linksounds like an interesting conceptbut how can you take the ideaforward?

If a Link is to be effective it shouldnot be entered into lightly. Whilethe enthusiasm of key individualsis very important, remember thata Link is an organisationalpartnership and needs to beembedded in the structure andfunction of the organisation.You need to gather interest fromwithin your organisation, includingsenior management, to ensurethat the partnership can besustained and bring about changein the long-term. Equally a Linkcannot just be a top-down decisionfrom senior management withoutsupport from other staff.

Six matters need to be consideredbefore establishing a Link. There isno set order for these to happenand the sequence will depend onthe individual circumstances ofyour organisation. This Chapteraddresses each of these stepsindividually:

Step 1: Establish a group ofinterested people

Step 2: Understand theimplications of your commitment

Step 3: Ask: Is a Link right foryour organisation?

Step 4: Define the aims

Step 5: Find a suitable Linkpartner

Step 6: Get agreement andsupport from your management

In the case of a UK FoundationTrust, agreement frommanagers as well as theBoard of Governors is veryimportant.

Step 1: Establish a group ofinterested peopleThere needs to be a group ofcommitted people who have theskills and time to make the Linka reality. From the DC partners’perspective this may meanpeople who have the motivationand drive to lead the Link,communicate with partners, andthink strategically about wherea Link can have an input. For UKpartners it may mean havingthe people with the professionalskills, time, contacts andexperience of working in a DC.Arrange to have an initialmeeting to explore the idea ofhaving a Link and establish whowithin your organisation isreally keen and willing tobecome part of the LinkCommittee. If a Board memberor chairman is enthusiastic andpart of the Committee thisusually makes things easierlater on.


CASE STUDY: Enthusiasm and reality in Links projects

I have been involved with health projects in Africa for more than 25 years now and still rememberthe excitement of my first time helping to set up a teaching programme. Since then there havebeen great encouragements. Probably the greatest for me has been seeing orthopaedic clinicalofficer students learn basic fracture treatment and then seeing them practising it in rural areas.There have also been great disappointments; probably the greatest have been when giftedstudents decide to leave their poor country in search of greener pastures. When one starts workingtogether with health care colleagues in less developed countries it is tempting to think that theroad ahead is one of continued improvement in services, sometimes slow, sometimes fast,sometimes hard, sometimes easy. The sad reality is that it is also sometimes downhill, and in manyplaces where I have worked the quality of health care is lower now than it was 25 years ago. Thereare many reasons for this, some related to personnel, some to equipment, some to inappropriatemanagement, some to general economic collapse, and the widening of the global rich / poor divide.I mention this, because at the outset of a Link it is easy to be over enthusiastic and it is importantto temper this with realistic expectations. Over optimistic hopes or promises can be detrimental toa project and can lead to personal disappointment and destructive cynicism. I have seen colleagueswho started off keen, gave much of their time and energy to a Link, then threw in the towel whenproblems occurred. If we are in this for the long haul we will rejoice with our DC colleagues atsuccesses and share with them in disappointments. That is partnership.

Professor Chris Lavy, Orthopaedic Surgeon

Step 2: Understand the implications of your commitmentBefore committing to a Link, you and your colleagues need to be sure that a Link is right for your organisation.How might a Link be able to help your organisation? Why do you want to get involved? Can you make a longterm commitment? Are you able to invest the necessary human and financial resources to running a Link?

REMEMBER!

When planning a Link it is tempting to ask your UK partner “What can you offer us?” But when Linkingwith an organisation you should be able to draw on expertise from across their staff. You need tochoose your partner carefully and ensure that they have all the skills necessary to support you. TheLink need not concentrate on just one disease, one area of health care, one objective, but can help todevelop different areas across your organisation. You should tell your UK Link partner “This is whatwe need, let’s discuss how you can help us”.

If you are a developing country (DC) organisation and you already have several collaborations withorganisations in other countries, it may be better to strengthen these than to start another one witha UK organisation.

REMEMBER!

The Link is about supporting and responding to the requests of partners in DCs. This does not meanthat you need to say yes to providing the requested x-ray machine or renal unit if you do not see anyevidence for these being top priorities. Neither does it mean making bold suggestions or focusing onissues that may be priorities in the UK without fully understanding the context. Instead it is about jointdialogue; what are your problems and priorities? How can these be addressed? What might we be ableto offer? Might a Link with us be able to help address some of these issues?

DC

UK

f

30


31

Step 3: Is a Link right for your organisation?The following decision tree will help you to think through some key issues when deciding whetheror not to get involved with a Link.

Decision tree for Link involvement

DECISIONTREE

Explore whatthe possiblebenefits of theLink will be toyourorganisation.

Be clear aboutwhat yourorganisationhas to offer.

ISSUES TO CONSIDER –

Developing Country organisation

• What is the vision of yourorganisation? Might a Link beable to help you to achievethis?

• If you don’t already have avision, might the Link help youdevelop one?

• Are staff in need of continuingprofessional development andon-the-job training?

• How will the Link improveservices to patients?

• Will your organisation becommitted to leading the Linkand prioritising its aims andobjectives?

• Have you considered whatstructures will be needed tomanage the Link?

• How will people be chosen totake responsibility and how willresponsibilities be divided up?

• Will you be able tocommunicate regularly withyour UK partner?

• Will your organisation be ableto arrange training sessionsthat your UK partners can feedinto?

• Will you be able to provide yourUK partner with transport andaccommodation when they arevisiting your organisation?

• Is your management willing tosupport the changes that willbe encouraged by the Link?This may involve supportingtrained staff with resources,personnel, equipment, etc. inorder to bring about thedesired changes.

• Will the Link be a catalyst forchange?


UK organisation

• Are many staff interested ingetting involved in internationalwork?

• Does your organisation serve alarge diaspora community? TheLink may help staff understandand address their needs better.

• Is there little cross-departmental interaction?Multidisciplinary teamsinvolved in Links may improveworking across yourorganisation.

• Is your organisation able torelease staff (e.g. 4 to 8) for atleast two weeks a year to workwith DC partners?

• Have you considered whatstructures will be needed tomanage the Link?

• How will people be chosen totake responsibility and how willresponsibilities be divided up?

• Are staff from across yourorganisation willing to getinvolved with the Link, maybegiving some of their free timeto support the Link?

• Is your organisation willing toarrange placements for stafffrom your DC partner?

• Are enough staff in yourorganisation willing to dedicatetime to managing the Link:planning, arranging meetings,fundraising, constantlycommunicating with DCpartners?

DC UKUNDER-PINNINGPRINCIPLES

Clear rationale

Responding torequests

Multidisciplinary

Flexibility

EqualCommitment

Organisationallyowned

Continued on following page...

2.1

DECISIONTREE

Understandwhere themotivation forthe Link iscoming from.Who will beinvolved?What supportand buy-in isthere for theLink?

Consider thescope forharmonisationwith nationalandorganisationalinitiatives.

What otherLinks doesyourorganisationalready have?


Developing Country organisation

• Is the Link something that yourorganisation has requested, willit respond to your needs? Or isit something that has beenoffered to you?

• Does the Link fit in to anyorganisational plans or nationalstrategic frameworks?

• Do management and staff alikefeel that the Link would bebeneficial? Are they willing tosupport it and get involved?

• Will the Link be able to advancenational and district initiativesor objectives? Can it helpnational and local strategicplans?

• Does your organisation alreadyhave ties with otherorganisations? If so can thesebe strengthened rather thaninitiating new partnerships?

• Can you explain why a proposedextra Link is needed?

• Are other local organisations orNGOs better able to help you toaddress the needs you haveidentified?


UK organisation

• Is the Link something that stafffeel they should be involved inpurely from a philanthropicperspective, or is there a realdemand from overseas for theexpertise that you possess?

• Will you have the capacity tothink and work strategically withpartners?

• Is there a genuine drive to workwith and support partners ratherthan ‘medical tourism’?

• Are those involved in a Linkwilling to respond to partners’needs rather than imposing theirown ideas and replicating what isdone in the UK? Are they readyto be stretched, challenged andto learn?

• Do management and staff alikefeel that the Link would bebeneficial in terms of their ownpersonal and professionaldevelopment? Are they willing tosupport it and get involved?

• Can you show how a Link canadvance the objectives of yourorganisation e.g. staffdevelopment and training,Corporate Social Responsibility,staff retention and morale,better cohesion amongst staff(particularly if there are stafffrom the potential partnercountry)?

• Find out if any other HealthLinks or partnerships with DCorganisations already exist? Isthere scope to strengthen theserather than initiating a newpartnership?

• If you proceed, is there a clearmutual understanding abouthow different Links cancomplement and support eachother?


Demand Driven

CapacityBuilding

Long-termsustainable Link

Harmonisation

Alignment4

Avoidingduplication

Decision tree for Link involvement


32


4 The Paris Declaration on Aid Effectiveness – endorsed on 2 March 2005, is an international agreement to which over 100Ministers, Heads of Agencies and other Senior Officials adhered, committing their countries and organisations to continue toincrease efforts in harmonisation, alignment and managing aid within a set of monitorable actions and indicators. Links need tobe aware of the principles of harmonisation and alignment to ensure that their work is in line, wherever possible, withgovernment plans (alignment) and that it avoids duplication of other initiatives (harmonisation).

DECISIONTREE

Carry out anorganisationalanalysis –what is thecapacity forlong-terminvolvement?


Developing Coutry organisation

• Is your organisation interestedin long-term collaboration?

• Will your organisation be ableto help monitor and evaluatethe outcomes of the work toensure it is meeting the agreedobjectives?

• Are there people who arewilling and able to create a LinkCommittee with a designatedcoordinator who has the timeand commitment to sustain theLink’s momentum?

• Will you be coordinating thework with otherpartnerships/Links that alreadyexist within your organisation?


UK organisation

• Does your organisation have thecapacity to see the Link throughover a long period of time?Are there any uncertainties orquestions in the future whichmay jeopardise the Link?

• Will you be able to set up a LinkCommittee to mirror and workwith the committee in your Linkorganisation?

• Will staff be supported and giventime to engage in Link activities?

• Can you get the management tosupport those with significantLink responsibilities by havingthese written into their jobdescription?

• Is your organisation able toassess and manage anyadditional risks incurred by beinginvolved in a Link?


Long-termengagement

Decision tree for Link involvement 2.1

33


G


34

DID YOU KNOW?

The resources needed to run a Link

The resources needed to run a Link successfully will depend on the objectives and activities thatyou agree with your partners. When determining these, it is important to be realistic about theresources available to both of you, taking care not to raise expectations beyond what you will beable to deliver. A modest start, strengthening the foundations of the Link while you build up yourfundraising capacity and Link team will allow you to deliver more effectively further down the line.

There are generally five types of resources needed to run a Link. These are:

• Funding (money) – to enable exchange visits, training courses and pay for other inputs such asbooks, journals and so on. A new Link may require about £5,000 a year to start its activitiesand an established one £30,000. In addition, administration time may also need to be funded.Usually the UK organisation takes a lead on fundraising with some input from the DCorganisation

• Time – to plan, manage, undertake, and evaluate the activities of the Link

• Expertise – to help achieve the objectives of the Link through support and training

• Hospitality – to support overseas partners on training visits

• Non-financial donations – such as books or equipment that you secure free through donationsor from old hospital stores. These come, however, with a strong warning and risk. Refer toChapter 2.6

Step 4: Determining the aimsof the Link

Before you find a UK partner,or while in discussions with apotential partner, you will needto assess whether a Link is theright way to respond to theneeds of your organisation and,if so, what the broad aim of theLink should be. While the topicof identifying aims andobjectives is covered in moredepth in Chapter 2.2 JointlyPlanning the Link, it is useful forthe DC organisation to have anidea about the purpose of theLink and its priorities at thisstage. It will help you find amore suitable partner andensure the relationship isdemand driven. If you havecarried out organisationalneeds assessments in the past,you can tie the work of the Linkinto these.

Ask yourself:

• Why do we need a Link?

• What other existingcollaborations do we have withoverseas organisations?

• What can a Link with a UKorganisation help us achieve?

If you are the Director/Manageror Dean of the organisation, youmight already have a clear ideaof what the purpose of the Linkshould be. Review yourorganisation’s 5-year plans (ifyou have them) as these will helpidentify areas where support isneeded. Involve other staffmembers in this process as youwill gain a broader understandingof the possible areas where a Linkcould help. This will alsoencourage organisational buy-inand ownership of the Link.

At this stage you will only bedefining the broad aims of theLink. Specific aims and objectivesmust be developed throughdiscussions with your UK partner.However, if you do have a clearidea of outcomes for the Link thiswill speed up the process ofcreating a Link and potentialpartners are more likely to takeyour request seriously.

When determining the aims of theLink it is worth remembering that:

• Your UK partners will not haveaccess to large amounts offunding for this work. The mainthing they can offer isprofessional expertise fortraining and supporting yourstaff. How can you best usethis?

• The principal focus of theLink should be to strengthenthe capacity of staff so theycan address the problemsthat have been identified.Activities such as trainingtrainers will help promotesustainability. You may wantto prioritise such activitiesas they are forward thinking,long-term and realistic.

• There will need to becommitment from staff andmanagers in yourorganisation to ensure thatvisits are followed up withaction plans and changesare implemented. Thetraining involved in the Linkwill typically be limited to anaverage of six exchange visitsper year so these need to beincorporated into a work planto be taken forward by yourorganisation.

Step 5: Finding a partnerOne of the first questions peopleinvolved in Links are often askedis, how did it all start? Each Linkwill have a different answer.Perhaps it was through a brokeringorganisation which helped them tomatch the partners, or throughpersonal contacts such as areturning volunteer, a healthworker who has emigrated to theUK but has been asked to supporthis/her home organisation, achance meeting at a conference oran existing school or communityLink.

When looking for a partnerorganisation:

• Investigate existing contactsin your organisation. Do anycolleagues have ties in relevantcountries? You may besurprised at the number of

individual or departmentalpartnerships that already existin your organisation. Share thisManual with them and assesstheir interest in expanding itinto a wider Link.

• Consider if other organisationsin your area have connectionsor twinnings with a particular

country. For example a SchoolLink, Community Link or aChurch Link may create a goodsynergy with a new Health Linkin the same region.

• Speak to colleagues in otherorganisations who are alreadyinvolved in a Link. See if theycan suggest any potential Linkpartners for you.


35

2.1

EXAMPLE

Carrying out a consultative needs assessment with yourDC organisation

A consultative needs assessment involves a broad range ofpeople. If you have not carried out an organisational-levelneeds assessment before and want to carry it out for thespecific purpose of the Link, here are some suggestions:

• Bring together key people from within your organisation(if you are large this may include heads of department,managers, matrons, doctors, lecturers or support staff).

• Encourage people to identify gaps between current anddesirable practice. Get them to specifically refer back toprevious organisational or national plans. The areas selectedshould be those that prioritise improvements in patientoutcomes rather than individual health workers. You couldask each participant to write three ideas out individually.

• Ask participants to then think about the solutions, focusingon learning/training needs.

• Each participant should then share their ideas verbally withthe group, highlighting the problems they have identifiedand the possible solutions. Write these down.

• As a group discuss each idea and rank them in terms ofpriority. You may be able to group them into broad themesfor example: improving neonatal services; improvingmanagement processes. Include the specific training needsyou have identified in each area.

• Write these down and include the rationale for your decisions.

• Now is the time to find a Link partner!

Remember, during the next stage of planning (described in 2.2)your UK partner may ask lots of questions. You need to justifywhy you have chosen the areas you have chosen, while beingwilling to learn from the dialogue (as they should be). Throughdiscussions with potential partners, you may decide to adjustyour aims and objectives.

DC

• While this Manual refers toLinks with UK organisations,the same principles apply toother countries. You maywish to develop a wider Linkwith another country. Referto Appendix 3 for a list ofother Linking organisationsoutside the UK.

• If you are a UK organisationyou may have a preference towork with one particularcountry, for example, if youserve a large diasporacommunity from thatcountry. Investigate existingcontacts with staff and see ifanyone has the contacts to‘broker’ a Link. Speak toother UK Link partnersalready working with thiscountry.

It is important to ensure that therelationship is demand driven (byDC organisations) rather thansupply driven (by UKorganisations) and that it respondsto need.

If, as a UK organisation, you aresuggesting the Link to a DCpartner, ensure that they aregiven a copy of this LinksManual and encourage them togo through an internal processof assessing whether a Link isright for them (as described inStep 3). Give them anopportunity to say no if theydo not show much interest.

Remember the Link will only beable to address specific issuesaround capacity-building andsupport. The DC partner may haveother pressing concerns which theLink will not be able to address.

As a DC organisation you needto be sure that a Link will be anappropriate response to anidentified problem, providing agreater benefit than the timeand resources required to run it.For example, when staff are ontraining courses there is anopportunity cost.

FIND OUT MORERead Appendix 5. It hassome key terms and healthsector context informationwhich you need to beaware of.


36

EXAMPLE

Criteria for selecting a Link partner

Experience suggests that the following points can beimportant when finding a Link partner.

• Match like with like. Aim to Link with an organisation of asimilar type to yours e.g. teaching hospital with teachinghospital.

• Explore existing partnerships. If your partner organisationalready has an existing partnership, it might be better forthem to strengthen this rather than start another. Whenresources are slender, concentrate them. However if itdoes seem appropriate to start a new Link make sure youare aware of what the other partners are doing.

• Ensure there is organisational support. Is there evidencefor wide support for the Link including from seniormanagement or are only one or two individuals engaged?An enthusiastic advocate can be useful at the beginning,but it is important to ensure that the Link doesn’t becomean individual project as it will not be sustainable.

And when selecting a DC partner, take into account:

• Clear evidence of need. Is there genuine demand from theDC partner? If the Link is to create change, the drive for itmust come from those who will implement the change inthe DC organisation.

• Ethos of the organisation and rationale for Link. Is theorganisation not-for-profit and engaged in work that is forthe public good? Does the organisation make provision forthose on low income to access its services?

• Geographical location. It is sometimes tempting to thinkthat the most useful Links are those that involve hospitalsor universities in the major cities in a DC. However, thesemay already have a number of existing partnerships. It isoften the smaller rural hospitals that have the leastoutside assistance and may gain the most from a Link.

u

UK

u


37

Step 6: Get agreementand support from yourmanagement

“The UK should see itselfas having a responsibilityas the employer of a globalworkforce and seize theopportunity to helpdeveloping countrieseducate, train and employtheir own staff.”

UK Government responseto the Crisp Report, pg 47

For the UK Link partner, gainingBoard support may be moredifficult to achieve than for theDC organisation. They will need tojustify why they are releasing stafffor overseas work, givenorganisational obligations andtargets.

A Link with high level supportfrom the ManagementCommittee, Board or Deaneryis much more likely to besuccessful and sustainable.Such endorsement will makethe Link engagement easier,as it may allow staff to taketime off for visits overseas orattending meetings. In somecases, the management maybe willing to go even furtherand support the Link financially– this might mean writing Linkresponsibilities into people’s jobdescriptions or supporting visitsoverseas, e.g. via paid studyleave.

To allocate NHS resources,such as staff time, you willneed to convince yournon-executives or governorsof the case for a Link. The tableon the following page sets outsome of the argumentscommonly used.

Unless a member of themanagement team has beeninvolved in setting up the Link,you will need to make an effortto get management support.Here are some ways you mightapproach this:

• Communicate with themright from the beginning toget initial endorsement forthe Link.

• Arrange a meeting to doa presentation on Links.

• Be clear what you areasking for. Organisationalendorsement and paid timewhen undertaking visitsmay be all you need at thebeginning. You will be in abetter position to ask formore once you candemonstrate what the Linkhas been able to achieve andthe benefits to staff in theUK.

The UK Board will also needto consider any legal orprofessional practiceimplications that may arisefrom having their staff involvedin the Link (see Chapter 2.11).You may want to invite a seniorperson from a neighbouringorganisation involved in a Link,so they can help convince yourBoard about the benefits ofbeing involved in a Link andhow they have dealt with anypractical issues.

2.1

GOOD PRACTICE

Avoiding supply-driven Links

Saying no is often difficult, especially when someone offersyou something that sounds like a good idea. But it isirresponsible to enter into a Link without carefully assessingwhether this is right for your organisation. It could be a wasteof time and resources both for you and your UK partner.Staff, who could otherwise be at the frontline treatingpatients, may be tied up hosting visitors or involved intraining that may have little impact on practice.

Before agreeing to the Link, make sure your organisationthinks about all the issues covered in this chapter. Assesswhether it is right for your organisation and what yourpriorities are. Will the Link be able to address these and be acatalyst for change? If you don’t think it will be of significantbenefit, say no.

DC


38

G

What’s next?When you have found a potentialLink partner it is time to startdiscussing the remit of the Linkin more depth. You will need toassess whether you are the rightpartners for each other andexplore areas for support. This willneed to involve a joint planningprocess (as described in Chapter2.2). It is also a good idea to setup a Link Committee at eachorganisation to take a lead onthe Link issues. Communicationis a key element of any Link soestablish good communicationchannels. These and otherlogistical issues are describedin Chapter 2.3.

DID YOU KNOW?

Culture shock

The phases of culture shockwhen travelling to a foreigncountry have been welldocumented. These are alsosimilar to the phases thatthose involved in thedevelopment of a new Linkalso go through. There is:

• A honeymoon phase, whereeveryone is a bit starryeyed.

• A negotiation phase, wherethere is some anxiety anddisappointment (sometimesaccompanied bydepression).

• An adjustment phase,where people are a bit morerealistic and meaningfullong term work can getdone.

EXAMPLE

Making a case for a Link to your Board

Some Trust Boards may be reluctant to get involved in a Link,and may find it hard to justify involvement with overseaswork. You need to produce a convincing argument, based onthe experience of Links and the regional/national Governmentpolicies. Some of the key points you may want to make are:

• Establishing an international Link will provide personal,professional and leadership development opportunities(regarded by some as better than attending traditionaltraining courses) for their staff.

• A Link will allow the staff to acquire skills in managingconditions and presentations rarely seen in the native UKpopulation but potentially increasing in the diversecommunities Trusts serve. It will also allow staff todevelop greater cultural awareness as the NHS workforceand populations they serve become more diverse.

• Exchange visits give staff a new perspective on their UKwork having worked in a resource-poor environment, andprovide a tool for recruitment and retention, motivationand reinvigoration of staff.

• Opportunities will arise for joint research, teaching andlearning.

• People from different parts of the Trust will work togetherin support of the Link – it is very good for interdisciplinarycommunications and broader team spirit.

• A Link can enhance the national and internationalreputation of the Trust and demonstrate Corporate SocialResponsibility in an attractive way, especially given theNHS history of recruiting health professionals fromoverseas. Links impart a sense of contributing tosustainable development in a situation where it is possibleto make a real difference.

• Political support for Linking schemes is increasing all overthe UK.

FIND OUT MORE

- Refer to Appendix 4 for a sample letter to your TrustBoard (UK)

UK

UK


39

}CHAPTER CHECKLIST

} Think carefully aboutwhether a Link is rightfor your organisation.

} Work through the issuesraised in the decision tree.

} DC: Establish the broadpurpose of the Linkthrough a consultativeprocess and communicatethis to potential Linkpartners.

} Approach your Board ormanagement team to askfor their support.

} Find an appropriatepartner.

} Now begin discussing thenext steps – planning theobjectives and activitiesof your Link.

2.1

2.2 Jointlyplanning the Link

40

Investing in a joint planning phasewill ensure that both partnershave a coherent vision and equalexpectations of the Link.One ofthe main challenges for Links isdefining realistic objectives thatare forward-thinking and will havea long-term impact.

Robust planning is an importantprocess for new and establishedLinks. Planning should be anongoing process rather than a one-off exercise and it should allow theLink to respond to changingpriorities and incorporate learning.

This Chapter takes you throughthe planning stages and suggestshow this can be done, who shouldbe involved and what the mainissues are.

In this Chapter:• The basics of

planning

• Stage 1.Preparing for ajoint planningprocess

• Stage 2.Identifyingpriority areas

• Stage 3.Setting (SMART)objectives

• Stage 4.Planning activities

• Stage 5.Monitoringobjectives andactivities



The basics of planningPlanning a Link needs to be ajoint process. The DevelopingCountry (DC) partner will be theone to identify the problems theLink can help address. They willidentify aims and suggestpriorities, ensuring they arealigned to national priorities.

The UK partner also needs tobe involved in the planningprocess to ensure they candeliver what is asked of them.The UK partner can also playan important facilitation role;asking questions about theneeds identified and stimulatingideas about how they can beaddressed.

Once a Link is established, theUK partner may be able to startmaking relevant suggestions,but at the start of therelationship this is unlikelyto be appropriate. Rememberto be forward-thinking andconsider the sustainabilityof what you are doing.

This five stage process forjointly planning a Link is thelogical route. In practice, it maynot be carried out in this order.N.B. This process presupposesthat the DC organisation hasalready determined the broadaims and priorities of the Link(see Chapter 2.1).

Stage 1. Preparing for a jointplanning process. Who shouldbe involved?

Stage 2. Identifying priority areas

Stage 3. Setting objectives(which may be SMART)

Stage 4. Planning activities

Stage 5. Review of outcomesand emerging objectives

Stage 1. Preparing for a jointplanning process.Who should be involved?In order to take the planning stageforward, the Link needs to bringkey stakeholders from bothorganisations together. Thisusually involves some members ofthe UK team travelling to the DCorganisation. But this should laterevolve in to a reciprocal trainingvisit arrangement.


41

2.2

KEY TERMS

Aims, objectives, outcomes, outputs and activities

Aims are the changes you hope to achieve as a result of yourLink. There might be a broad aim for the Link (e.g. To improvequality of care through the training of health workers) as wellas specific aims which may vary over time (for example:improve infection control within the hospital; improve triagesystems; develop CPD for nurses).

Objectives are more detailed and specific statements aboutwhat those involved in the Link will be able to do as a resultof its establishment. A Link is likely to have severalobjectives, which contribute toward the aims. An objective isa description of an intended outcome. One objective of theLink might be, for example, to reduce rates of infection in theburns unit by 70% in six months.

Outcomes and outputs should not be confused. An outputrefers to what was done (20 nurses from the burns unittrained in infection control) whereas an outcome is the endproduct, the direct result of the project. In a well plannedproject, the outputs should lead to the achievement ofoutcomes (50% reduction in infection rates in the burns unitsix months after the training). Both outputs and outcomesneed to be measurable and should be monitored.

The Link will need to decide what activities it needs toundertake in order to bring about the intended outcomes.

Objectives and expectations may change after an initial visitand as the Link develops. A flexible approach is needed totake account of changing issues, especially in the DC. Makesure these can be revised and updated when necessary.

a

REMEMBER!

Your aims will determine thestructure of the UK team

You need to share the aimsof the Link that you haveidentified (see p34-35) withyour UK partner in order tohelp them decide who arethe most appropriate teammembers to be involved inthe initial planning process.You should try to:

• Share the key areas (aims)that you have suggestedthe Link can engage with.

• Share any strategy orpolicy documents i.e. yourorganisation’s work plans,MoH/MoE/district strategyplans or policy documents.

• Suggest a good time forthe first visit from your UKpartner (remember to allow3-6 months to plan thisvisit). Avoid nationalholidays and busy periods.If the visit takes placebefore the start of thefinancial/ planning year itwill allow you to incorporatethe work of the Link intoyour organisation’s plans.

• Inform your UK partnerof the names of the keypeople involved in leadingthe Link and contact detailsof the people they shouldliaise with to prepare forthe visit.

It is important to select the rightteam to take part in the planningvisit. Representatives from bothorganisations should involve staffwith a combination of decision-making powers and specialistknowledge relating to the specificaims of the Link.

For the UK planning team it isdesirable that at least onemember of the party is a seniormember of staff who canauthorise decisions and showcommitment to the partnership.Ideally another should haveexperience of working in adeveloping country. If the Linkinvolves a teaching component(and the partner is an NHSTrust) invite someone from therelevant faculty from your localmedical or nursing school toaccompany you. Refer also toChapter 2.4 for further practicaltips about visits.

GOOD PRACTICE

Size of planning team

The initial planning teamshould be small, between 2and 3 people, and need notvisit for more than a weekunless they are going to startactivities. Involving morepeople will incur considerablecost which could be betterused at a later stage whenthe Link is actually startingto implement activities.

Be prepared for last minutechanges to the programme inthe DC due to local priorities,and use opportunities as andwhen they arise to meet keypersonnel.

The core group from the DCshould involve senior membersof staff and those involved inthe priority areas which youhave identified. Make sure youinvolve a wide spectrum ofpeople, as your UK partners willbenefit from meeting staff at alllevels within your organisation.Think also about whether youshould involve other officialssuch as District Directors ofHealth, members of the Ministryof Health, or people fromassociated organisations. Tryto inform them about the newcollaboration you are engagingin and get their support fromthe beginning.

If the aims for the Link, asestablished by the DC partner,are clear before a first visittakes place, it may beappropriate to combine theplanning visit with someteaching / system developmentwork. While this will only bedelivered on a small scale andis unlikely to be the primaryaim of the visit, it will help bothpartners to understand what ispossible in a given time, whatthe constraints are, and give ataste of what the Link can offer.

REMEMBER!

The initial planning visitis a time to buildrelationships, establishwhether you are the rightpartners for each otherand assess the feasibilityof forming a Link.


42

!

DC

UK


43

GOOD PRACTICE

Preparing for the planning visit

Before the visit, read as much as you can about the health system and the socio-political contextin your partner’s country. The more you know before a planning visit, the better able you will be tounderstand the context and ask the right questions. In addition to any information your partnerssend, you might want to read:

• Any policy/strategy documents produced by the Ministry of Health (occasionally available ontheir websites). Remember the importance of alignment principles in the Links work you areundertaking (see p33).

• Find out about what other development agencies are doing in the area (in relation to thepriorities your partner has identified). This might include the WHO, UNICEF, PEPFAR, GAVIAlliance, DFID, JICA and other bi-lateral donors. This will give you an idea of the areas thatare already being supported, and that may have special funding streams. it will also help youget an initial understanding of where the gaps are.

• Try to understand the context in which your Developing Country partner works. For example;where are the main health training organisations? What are the doctor and nurse to populationratios? Who are the key players in the health sector? What is the role of traditional healers?What are the main specialisms of health workers?

• Understand and gather information about other Links in that particular country or similarcircumstances e.g. isolated areas or post-conflict environments.

FIND OUT MORE!

Refer to Appendix 5 for further information on issues to consider.

2.2

CASE STUDY

The importance of making more than one contact

Many countries are characterised by a shortage of health workers so you may find that yourin-country contacts are restricted to just one or two people. This is what the Scotland MalawiMental Health Education Project found. “Our Link was initially established under the guidance ofthe only local psychiatrist, who proved a great source of local knowledge and encouragement andadvised us on what was needed locally and where to target our efforts”, says Leonie Boeing, oneof the founding members. But it is important to involve a wider range of stakeholders to ensurecontinuity, sustainability and local ownership. “As we had such an authoritative contact weneglected this but later realised that it was important we have now made close contacts with theleaders of the other organisations that we were working with, for example the Dean of the Collegeof Medicine. We have come to realise that getting wide ownership for the Link is key. We now havea wide and very supported Link with the key local leaders involved; we are hopeful that the Linkwill be truly sustainable.”

UK

UK

UK

Stage 2. Identifying priorityareasYou have now shared the aims ofthe Link and mobilised teams fromboth organisations to cometogether to plan the Link. Thechallenge now is to review thebroad aims of the Link (if you havethem), work with them to turnthem into realistic objectives anddetermine the activities the Linkneeds to carry out to achievethem.

If there is a long ‘shopping list’ ofneeds, how will the Link prioritisethe most important ones to focuson? This first section helps youthink about some of these issues.

FIND OUT MORE

Managing change

Refer to Chapter 2.7 tounderstand and overcomesome of the barriers whichmay prevent change fromhappening.


44

EXAMPLE

Whose needs?

Identifying the needs of your organisation and the objectivesof the Link will be a consultative process involving differentpeople who are familiar with the main departments in theorganisation. Every person is likely to highlight differentproblems that they are facing. You may end up with a long listof requests, with each person identifying their own priorities.For example, in the case of a hospital, you may find:

• The lab technicians want to be able to carry out a widerrange of diagnostic tests rather than sending samplesaway, as this would allow them to produce results moreefficiently and potentially save more lives.

• The Director is keen to improve infection control withinthe hospital and reduce maternal mortality rates due toinfection after caesarean section on the ward.

• The tutor of the nurse training college affiliated to thehospital wants to support the development of apreceptorship programme for the student nurses as thiswould improve their learning and care of patients.

• The Ministry of Health has just released a strategy papersaying that non-communicable diseases will be increasingand appropriate services need to be developed. You areseeing increasing number of diabetes patients but areunable to adequately respond to their needs.

• Some patient groups have formed and are starting todemand a say in the improvement of services. You haveheard that patient participation is a significant feature ofthe NHS. Perhaps your Link with the UK could help feedtheir views into planning better services for patients.

You know the Link can only address a few of the issues in thefirst year, but which ones should you focus on? It is importantto review these in order of priority once a year, and include aplan for monitoring and evaluation of their development. Thenext section should be able to help you think through some ofthese issues.

DC

u


45

ISSUE

Ability of UKpartner to deliver

Numbers ofbeneficiaries

Types ofbeneficiaries

Length of time toachieve desiredoutcome

Systems andorganisationalsupport

Aligned to priorities

Sustainability

Fundingopportunities

RATIONALE

Does the UK partner have the expertise tosupport the required areas? Is the UKpartner able to bring another organisationon board to help provide specific expertise?

How many people (staff, students, patients)will benefit? What are they health outcomesthey are likely to experience?

Who are the beneficiaries? Are they thepoorest patients or those with the leastaccess to alternative health services?

How long will it take to achieve the desiredoutcome? Sometimes there are ’quick wins‘that deliver effective results over a shortperiod of time during the initial stages of aLink. This will help raise people’s enthusiasmfor the Link both in the DC and in the UK.

How will the management support thosewho have received training through theLink? Will resources (staff, trainingmaterials, equipment) be made available sothat people can put learning into practice?Is lobbying and support specifically requiredto meet the objectives? Can the Link helpwith this?

Are the objectives an established prioritywithin your hospital/ district/ country?

Will the training and support deliveredthrough the Link have a long term impact?

Donors’ funding criteria will determinewhether the work is eligible for funding.While the objectives of the Link should notbe driven by access to funding, it may be animportant consideration.

2.2

UK

When prioritising the objectivesthat you want the Link to focus on,think about the following issues:

REMEMBER!

UK remember yourneeds too

As a UK organisationinvolved in a Link you willalso have your own reasonsfor wanting to be involvedin the Link and, for thepurpose of sustainability,it is important to ensurethat these are being met.For example, some UKorganisations frame theirinvolvement in Links aroundContinuing ProfessionalDevelopment for staff.Others may be interested injoint research opportunities.There are also opportunitiesfor learning and teachingglobal health education.Some Links have alsomanaged to get jointaccreditation for work withinthe Link. It is essential tobring up these issues anddiscuss them with your DCpartner during the planning.

!Stage 3: Setting (SMART)objectivesOnce you have established theLink’s priorities it is time to writethese up as specific objectives.Remember that a Link may haveseveral objectives that contributetowards an overall aim. It is goodpractice to make them as SMARTas you can during the planningstage, as this will stimulatediscussion and clarify exactlywhat you are trying to achieve.The acronym SMART refers toobjectives that are:

S – SpecificM – MeasurableA – AchievableR – RelevantT – Time-bound

At the early stages of the Link itis legitimate to decide that youdon’t have all the information tomake them as SMART as youwould like. Alternatively, if youdo create SMART objectives fromthe beginning, you may well laterdiscover that they are notappropriate and need to re-writethem. Flexibility is important.

REMEMBER!

The Link should address aparticular problem and helpcontribute towards a solution.The best solutions are simplechanges in practice whichmay improve efficiency andquality. Managing this changerequires careful thought andit is worth considering whatfactors will help promote andbring about change. This isdealt with in further detail inChapter 2.7 on managingchange. When planningobjectives cross-refer to thisChapter.

FIND OUT MORE

Read Appendix 5. It hassome key terms and healthsector context informationwhich you need to beaware of.


46

u


47

EXAMPLE

Defining SMART objectives for your Link

SMART objectives help you to add precision to your stated intentions so that those involved inimplementation have a clearer idea of what they need to do. The task of monitoring and evaluationis also made easier with SMART objectives. This section provides a worked example of how to makeobjectives SMART.

A NON-SMART objective: To provide training to midwives at Kiguri District Hospital (DC)to reduce the numbers of caesarean sections performed.

SPECIFIC: To provide training to midwives at Kiguri DC on how tosafely use forceps to manage delayed second stage labour usingWHO protocols to reduce the numbers of caesarean sectionsperformed.

MEASURABLE: To provide training to all (8) midwives at KiguriDistrict Hospital through theoretical sessions with auditedattendance and hands-on training with log book-recorded cases toreduce the incidence of caesarean sections due to delay in secondstage labour by 50%. This will be recorded for a period after thetraining and compared to a similar period prior to the training.

ACHIEVABLE: This depends on the time scale of the support and thenumber of deliveries. To train all 8 midwives with hands-on expertise insix weeks is unrealistic – it would be more reasonable to train 1 or 2and build from there. It is also not appropriate to set a specific target(50%) for reduction in Caesarean Section. It is better to measure theresult and then hopefully demonstrate improvement.

RELEVANT: Local data shows that caesarean delivery rates at KiguriDH are 30% which is higher than expected for this population. Theincreased CS rate increases maternal morbidity and mortality in thispatient group by increasing the risk of abdominal sepsis (with 2 in 5experiencing wound infection post abdominal delivery) and uterinescar rupture in subsequent pregnancy delivering in rural setting.Therefore reduction of CS by any auditable intervention presents apossible health gain. Especially if this can be delivered in a cost-effective way.

TIME-BOUND: To provide training between March and December2009 to midwives at Kiguri District Hospital.

A SMART objective:

To provide training to midwives at Kiguri District Hospital on how to safely use forceps to managedelayed second stage labour using WHO protocols. Training will be carried out between March andDecember 2009. At least 2 midwives will receive in-depth training and the remaining ones willreceive an introductory session. This will be done through theoretical sessions with auditedattendance and hands-on training with log book-recorded cases. This will be recorded for a periodafter the training and compared to a similar period prior to the training. The aim is to reduce theincidence of caesarean sections due to delay in second stage labour.

For more information on SMART objectives and their importance in monitoring and evaluation referto THET’s M&E Toolkit (see p89 for details).

u 2.2

!

!

Stage 4. Planning activitiesWhat activities need to be carriedout to achieve the desiredoutcomes or objectives? Thismay include a combination ofthe following:

• Training or support visitsfrom the UK partner to theDC organisation. Think aboutthe purpose of these visits,expertise required and duration.This will help you begin toidentify suitable people. Referto Chapter 2.4 for moreinformation on this.

• Training visits from the DCpartner to the UK to theorganisation. Think about thepurpose of these visits, theexposure required, duration,etc. Chapter 2.5 has furtherinformation on this.

• Mentoring and support bythe UK partner for specificactivities.

• Training material, books, andso on need to be provided.

• Equipment needs to beprovided. See Chapter 2.6for more information.

Sample activity plan

• Steering groups in each of thepartner organisations will helpto monitor and share feedbackwith one another in relation tothe activity plan once it hasbeen agreed.

REMEMBER!

Links sometimes place toomuch emphasis on visits.Although visits areimportant, what happensbetween visits is probably asimportant in determining theoutcome of a Link. Ongoingcommunication, monitoring ofactivities, completing agreedactions, follow-up after visitsand exchanging informationare also key components.This should not be forgottenwhen planning activities.

Some activities will involve bothLink partners working togetherwhile other responsibilities mayfall individually to the UK or theDC partner. You may want to setthese out clearly within specifictime scales so that everyone isaware of their responsibilities.

REMEMBER!

After you have determinedthe objectives and activitiesfor the Link, think about howyou will monitor and evaluatethem. Determine SMARTindicators as detailed inTHET’s M&E Toolkit(see p89).

After you have defined theactivities that the Link will carryout, check that the sum of thesewill result in the intendedoutcomes and aims of the Link.


48

WHAT? WHO? WHEN? RESOURCES NEEDED?

(List activities) (Who is responsible) (To be completed by...) (Funds, skills or materials)

1.

2.


49

SMARTObjectives /Outcomes

Activities ofthe Link

rr

rrPLANNING CHECKING

G DID YOU KNOW?

The sum of activities and their outputs should result in theintended outcomes of each Link objective. Once you havea detailed list of activities you plan to carry out, workbackwards to check what the sum of activities will result in.Is this what you are expecting? Are there any missing phases?

Aims ofthe Link

G 2.2

Stage 5. Monitoring objectivesand activitiesStages 1-4 of this Chapter haveaddressed the initial planning of aLink. But sometimes you may findthat things change rapidly withinthe DC partner organisation.Issues that you included in a two-year activity plan for the Link in2008 may be out of date by 2009when the DC organisation has aset of new strategies.

Regular review is therefore veryimportant: assess whether theoriginal plans are still prioritiesand make any necessarymodifications. Your Link shoulddo this in two ways. The LinkCommittee responsible forplanning the Link should regularlyreview the overall direction andplans for the Link. In addition,those engaged in individual Link

visits, both to the UK and the DC,can take a lead on planning thefuture work of their own work-streams and feeding back to theLink Committees. Remember theimportant role of monitoring andevaluation and ensure it isincorporated into your work.

DID YOU KNOW?

The Weakest Link

Reasons why a Link may notbe successful:

• Objectives are unrealisticor not properly definedand agreed.

• Poorly informedinterventions or simplisticproject planning.

• Inadequate resources.

• Lack of ongoingcommunication.

• Weak leadership.

• Weak control of processesor feedback mechanisms.

CHAPTER CHECKLIST

} Invest in robust planning.

} The DC country partnerneeds to do preliminarywork to set the broadaims of the Link.

} Define objectives andactivities in a jointplanning process involvingUK and DC partners andagree them in writing.

} Activities need to bealigned to strategypapers.

} Review the objectives ofa Link on a regular basis.This may be done aftereach Link visit or onceevery year.

}

2.3 Coordinatingthe Link

50

If a Link is to make an impact andcreate change it needs to be wellcoordinated and managed. Gettingthe right systems in place at thebeginning is a good investment.This Chapter considers theseimportant elements:

• Having an effective LinkCommittee in each partnerorganisation

• Working in partnership toestablish good methods ofcommunication

• Building up the work of Linksto create an organisationalmemory

• Having effective andtransparent systems formanaging funds

In this Chapter:• Establishing a Link

Committee

• Communication

• Record keeping

• The Link InductionPack

• Developing aMemorandum ofUnderstanding

• Registering as acharity

• Managing andtransferring funds



Establishing a Link CommitteeFormation: Link committees tendto form more easily in the UKorganisation as the UK partneroften takes a lead on fundraising,without which the Link would havedifficulty operating. But if the Linkis to be demand driven, then it isvital that the DC organisation hasa Link Committee or an effectiveco-ordinator who communicatesregularly with the UK team. TheLink should have a core group ofpeople (ideally more than 4) inboth the UK and the DevelopingCountry (DC) organisation whooversee and drive the work of theLink forward.

Communication: Regularcommunication between the twoLink Committees – either throughthe designated Link coordinatorsor the group via e-mail – is vital toensure a healthy Link. Linkcoordinators/ committees shouldaim to talk regularly to updateeach other on progress againstagreed plans.

Involvement: Some Links chooseto have a small committee drawingon volunteers from outside thecommittee to carry out specificactivities (e.g. visits overseas,fundraising and publicity). OtherLinks have larger committees,ensuring that all individuals whotake part in overseas visitsbecome active members of thecommittee. The latter modelensures the Link management isinclusive and those involved invisits can continue to contribute toother activities. It also helps theLink to become organisationallyowned and less susceptible to staffturnover. The Link Committeeshould feedback to the widerorganisation at least once a yearto show progress and encourage

ownership of the Link amongcolleagues and patients (thecommunity).

EXAMPLE

Members of a UK hospitalLink Committee

It is important that the seniormanagement of the hospitalare involved as well asmedical, nursing, academicand administrative staff.Enthusiastic individuals canbe recruited to superviseparticular activities such asfundraising, publicity andfinance. Possible compositionof the steering group:

• Links Coordinator

• Medical Director/Boardmember

• Clinician

• Nurse

• Fundraisers

• Treasurer

• Post-graduate Dean (if itinvolves a medical school)

• Influential lay person /community leader

As the Link grows it might beuseful to divide the team up intodifferent sub-committees withseparate responsibilities, forexample:

• Work stream leads – takingforward each of the identifiedobjectives of the Link

• A secretary or knowledge –management group – whoensures that records are keptup to date, people have clearterms of reference and givefeedback after visits; whoproduce a briefing pack, etc.

• A fundraising team who takethe lead on raising funds(see Chapter 2.9 for furtherinformation)

• Monitoring and Evaluationgroup

• Equipment team – if books andequipment are an importantelement of your Link

• A communications committee– maybe from thecommunications departmentwithin your trust who can be incharge of publishing articles,producing posters and generallyraising awareness of the Link(may only be relevant to UK)

GOOD PRACTICE

Raise awareness andget people involved

• Have a public meeting andtalk about the Link. Youmight want to ask for ashort time slot at a meetingwhich has already gatheredpeople together for anotherpurpose.

• When people are involved inoverseas visits, invite themto become part of the Linkteam as their knowledgewill be very valuable.

• Find an opportunity to talkabout the Link at apostgraduate weeklymeeting and invite peopleto get involved or donate.

• Invite people to take part:maybe advertise forparticular roles andresponsibilities within theLink team.

• Use staff newsletters andother information outlets tokeep the wider communityinformed.


51

2.3

u

Ed

CommunicationThe importance of goodcommunication between Linkpartners cannot beoveremphasised. Communicatingbetween visits is very important,whether this is to providefeedback on a previous visit, planfor the future, discuss issues, or

provide support throughmentoring. If communicationbreaks down, it can cause oneor both partners to becomedisillusioned, perhaps suspectingthat the other partner has lostenthusiasm for the work. A lackof communication can also be anexcuse for inactivity for those who

let other priorities takeprecedence. Both the UK and DCpartners need to make an effort toregularly communicate with eachother. The following table providesexamples of methods you can useto communicate.


52

MEANS OFCOMMUNICATION

Telephone

Skype or instantmessaging

SMS/textmessage

THINK ABOUT

In the UK most people use a fixedtelephone line in their office but inmany DCs mobile technology is moreeffective. Exchange the numbersthat are the easiest to use.

Agree in advance with yourorganisation if they will allow you tomake long distance calls as part ofthe Link, otherwise opt for adifferent method. As long distancephone calls can be expensive, youmay decide to use other methods ofcommunication.

If there are important issues todiscuss involving several people andif your phones have a loud speaker,you could think about arranging ateleconference.

If you and your Link partner have agood internet service, you may beable to use systems like Skype whichallow you to talk to each other overthe internet free of charge.

Mobile technology is proliferatingthroughout the world and textmessages (SMS) via mobile phonescan be a cheap, easy and quick wayof relaying a brief message to yourpartner.

TIPS

When calling from the UK you can getcheaper phone calls by using an access

code company. Check out the best rates forthe country you are calling by putting cheapinternational calls into a search engine.Alternatively you can buy a calling cardoffering cheap calls, or even better, useSkype.

To make an international call dial ‘00’ or ‘+’followed by the country code. Sometimesyou need to drop the first ‘0’ of the number.

For DC making calls from a DC to theUK can often be more costly than vice

versa. If you need to discuss somethingurgently with your partner, ask them if theymight be willing to call you back. Agree atime and day convenient to you both. If youare unable to make international calls letyour partner know and agree on a bettermethod of communication.

See www.skype.com to download theprogramme and see the necessaryrequirements.

If you have sent an important e-mail or areabout to courier a document to your Linkpartner and need to confirm the address,send an SMS to make the recipient aware ofthis.

UK

DC



53

MEANS OFCOMMUNICATION

Email

Fax

Postal letter

THINK ABOUT

Email is often the communicationmethod of choice in the UK. Youmay even find people working inthe same office communicating viaemail.

If it is checked regularly, emailcan be useful for sending quickmessages and longer documentswith attachments.

However regular access to acomputer and the internet may notbe easy in some environments, sobefore relying on it as a method ofcommunication check that yourpartner has regular access to it.

In DCs, broadband is not usuallyavailable. Connections maybe slowor unreliable.

Fax can be useful to senddocuments if there is a wellfunctioning phone line. You maywant to send a printed copy of anemail by fax as well to ensure thatit reaches the designated person.

You may wish to use ‘snail mail’when sending importantdocuments, if a signature is needed(e.g. MOUs), photographs, or just todouble check that your partnershave a physical copy of anydocument you have sent usinganother method.

TIPS

If you are sending attachments makesure they are compatible with your

partners’ computer. For example if you aresending a word document and using MicrosoftOffice 2007, save it in an .doc version so thatit can be opened with older software.

Be aware that attachments can take a longtime to download. Where possible, minimisethe size of attachments or avoid sending themby including information in the body of theemail instead.

Viruses can also be a problem whenreceiving emails. Make sure your

computer has an updated anti-virusprogramme.

Ensure that you get a delivery report toconfirm that it has reached the fax machineit was intended for. Fax numbers are dialled inthe same configuration as telephone numbers.

Remember that postal services can takesome time to reach their destination, andallow three to four weeks if you are using anormal service.

If it is urgent you may want to use a couriersuch as DHL who will be able to guaranteewhen it gets there by. Note that these servicescan be expensive.

EdGOOD PRACTICE: Teleconferences

Regular communication between Link organisations is very important, especially if the Link hasreceived project funding. Teleconferences can be an effective way to do this.

After securing funding from DFID’s DELPHE scheme administered by the British Council, the Oxford-Dar Link needed to find an effective way to communicate regularly with each other. “We have madeweekly teleconferences a key activity for keeping the project going”, says Petronella Joy Mwasandubefrom Ferndown. Project leads from the UK and Tanzania dial in to a set number.

“Our teleconference usually last for an hour. This gives all project leads equal opportunities todiscuss, participate and update others on key activities as well as question and agree the wayforward. Teleconferencing has proved to be an excellent way to enhance learning and exchanging ofideas and keeping the momentum going.”

2.3

UK

DC

Record keepingKeeping good records is importantfor organisational memory(remembering what has happenedin the past). This in turn isimportant to avoid duplication andto ensure that new members ofthe Link know what has happenedbefore their involvement.

Both the UK and DC Link partnershould have a folder that isdedicated to the Link and holdsthe same documents. If you havea meeting and produce minutesmake sure to share these withyour Link partner. Equally, visitreports should also be shared.The items that your Link foldermight contain are:

• Initial correspondence aboutthe Link

• What you have agreed the Linkwill do. The aims, objectives andactivities of the Link

• Any changes or additions tooriginal plans

• Minutes of meetings from boththe UK and DC partners

• Visit reports: focusing onactivities, outcomes and follow-up from both the UK and DCpartner

• Minutes of any Board meetingsor presentation about the Link

• Any policy documents /preparation packs for stafftravelling with the Link

• Name and contact details of thekey people who are involved

• The signed MoU of the Link

REMEMBER!

When corresponding by letteror email send a copy to morethan one person from yourpartner organisation (andcopying in your owncolleagues too) so thateveryone has a record of thecommunication and it doesnot end up in an informationbottle-neck.

The Link Induction PackA Link Induction Pack whichprovides practical planninginformation when visiting partnersis a vital briefing document. Ideallyboth UK and DC partners shouldhave their own Induction Packswhich are built up over time. Thiswill ensure that Link participantsare fully prepared for their visit.

The information in Chapter 2.4and 2.5 provides specificsuggestions of areas which shouldbe addressed in the Induction Packso cross-refer to these Chapterswhen developing Link Inductionpacks. The broad areas you maywant to include are:

• The purpose of the Link, what itis trying to achieve and a copyof the latest plans.

• Information about the healthsector in the partner country.

• Reports from previous visits,what was done and what wasagreed (this will help people toavoid duplicating what hasalready been done orcontradicting what has alreadybeen agreed).

• Background of the country –information on the history,geography, politics of thecountry or local area.

• Advice on planning beforeyou go, including tips on whatto pack, booking your flights,immunisations and prophylaxisetc.

• What to expect – helpful tipsand advice on facilities,climate, costs of local itemsand services, culturaldifferences etc. Photo albumsand video-clips are very useful.

• Who pays for what. Whatexpenditures are covered bythe Link and how claimsshould be made.

• What to do in case ofemergency.

• Who’s who in the partnerorganisation, includingmanagement and all those whohave been involved in Link work.Include their contact details.

• Other useful contacts. You couldinclude contact details of otherhospitals or doctors in the area,embassies, international NGO’s,UN and WHO representatives.

• Key phrases in the locallanguage – perhaps ask one ofthe Link partners or a memberof staff who has already beenon a visit to put together a listof useful phrases to learn.

• Risk assessment policydocuments and health andsafety guidelines.(See Chapter 2).

But don’t reinvent the wheel –ask if you can see the InductionPack of another UK Linkpartnered with the samecountry, and adapt this asnecessary.


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2.3

/

UK

REMEMBER!

Give those involved in Linkvisits a chance to contributetowards and update theInduction Pack after eachvisit.

Developing a Memorandumof Understanding (MoU)It is good practice to devise anMoU between Link partnerswhich defines some of the broadprinciples within which you agreeto work together.

A clear MoU sets out theparameters of the relationship andmakes it clear who is responsiblefor what. It will aid those involvedin managing and implementing theLink. The MoU should be a livingdocument which is regularlyreviewed and updated by bothparties. An MoU could be draftedduring the initial planning visit butit may be better to refine it andsign it when the partnership isbetter established.

FIND OUT MORE

Refer to Appendix 6 fora sample MoU.

Registering as a UK CharitySome Links choose to registeras a charity in the UK. Some ofthe main advantages of beingregistered as a charity are:

• Tax relief on donations

• Being eligible to receivefunds from a wider range ofgrant-making trusts

• Increased legitimacy

However, registering as acharity can be a complicatedand bureaucratic process whichdoesn’t end here. Once youhave registered, there are strictguidelines around governanceand management which need tobe adhered to. Every charity hasto have a governing documentthat sets out its objects andhow it is to be administered.A charity which is set up as aTrust will also need to have aBoard of Trustees.

FIND OUT MORE

A charity is a not-for-profitorganisation that undertakesactivities which contribute tosociety and is registered bythe Charity Commission,which acts as a regulator.Once registered, all charitieshave to obey a numberof rules, which includeregulations coveringtrustees, accounts, financesand management. TheCommission now offers anon-line application service,introduced to make the wholeprocess quicker and easier.Further information can beobtained from:

www.charityfacts.org

www.charitycommission.gov.uk

Making the decision whether toregister your Link as a charitywill be a case of weighing thefinancial advantages associatedwith charity status against theadministrative disadvantages.The benefits of charity statusare mostly financial (i.e.claiming tax back on donations)and this will depend on the sizeand budget of the Link.

“I would advise Links toregister as a Charity assoon as it is apparent thatthe Link is feasible andsustainable”

Dr Cath Taylor,Pont-Mbale Link.

Some NHS and universityorganisations however, maybe opposed to staff membersbecoming involved in work-related charities. Charity statuscould result in the Link beingperceived as somethingseparate and not embeddedin the organisation. Yourorganisation may already havecharity status and support aswell as a number of individualprojects which the Link couldalso become part of, without theneed to register as a separatecharity. You will need to makethe decision according to theindividual circumstances.

Managing and transferringfundsAny funds raised for Link activitiesneed to be kept in a bank account.If you are applying for grants fromlarger donors they will want to seeevidence of your banking andaccountability procedures so it isgood practice to establish effectivesystems from the start, even whenthe amounts you are managingmay seem small.

Most Links find that it is the UKpartner who manages the bulk ofthe finances (as this tends to bewhere money is raised). The UKpartner makes transfers overseaswhen needed. Some Links havetheir own designated charity bank

account for the Link and othersask the finance department oftheir organisation to managethe funds. If you manage fundsthrough the NHS, fundraisingand financial managementshould be carried out inaccordance with both nationaland local NHS policy and localStanding Financial Instructionsand Standing Orders. If you setup a charity account, the

Charity Commission setsnational rules (www.charity-commission.gov.uk) and theNational Council for VoluntaryOrganisations can also provideadvice. Whichever approach youchoose, ensure that you havetransparent systems and provide aregular summary of accounts toboth Link Committees. Be aware ofthe financial risks of fluctuationsin foreign exchange rates whenholding cash in foreign currencies.

CHAPTER CHECKLIST

} Establish an effectiveLink Committee tomanage the Link withineach partner organisation.

} Find appropriate methodsand lines ofcommunication.

} Keep good records foryour Link and make themaccessible to all thoseinvolved.

} Create an Induction Packfor visits to your overseaspartner which is updatedregularly.

} Develop an MoU betweenyour two organisations toformalise the Link.

} Ensure effective andtransparent managementof funds.


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GOOD PRACTICE

Transferring funds to the DC partner

• Before making a transfer, agree a budget that shows howthe money will be spent. This should be split into budget linesrelating to individual activities.

• Money should be sent according to the agreed budget.

• Transfers can be made to the DC organisation bank account(although some accountants don’t like this as it looks likethere is more money coming in to the organisation which maydisplace other government funds). Find out if there are otherbank accounts for donations that can be used and ensurethat it will be easy to withdraw the money before making thetransfer. Avoid transferring funds to an individual’s bankaccount as both parties will be criticized for this and it mayraise suspicion.

• If the Link needs to open its own bank account, ensure thereare two signatories on the account. Ideally one of whom willbe directly responsible for the day-to-day running of theproject and the other person will be overseeing the work.Both persons should be affiliated with your partnerorganisations. Banks may make charges, so ensure youare notified of these in advance.

• Remember to keep statements, transaction sheets and allreceipts so that you can compile accurate financial recordsand account for funds you have been given.

}

Photograph (right): John MacDermot, Somaliland

UK

Health leaders of tomorrow– trained with the help ofrepeated Link visits.

2.4Visits to theDeveloping Countryorganisation

58

Training visits are likely to be a keypart of your Link which will helpyou to achieve the Link objectives.

Working face to face, sharing ideasand collaborating with others canbe a very enriching experience forall those involved. This Chaptertalks you through some of thelogistical issues when planningvisits from the UK to theDeveloping Country (DC)organisation. While this Chapteris mostly aimed at UK partners,issues around planning are alsorelevant to the DC. Chapter 2.5looks at visits from DC partnersto the UK.

In this Chapter:• Who should be

involved?

• Visit durationand time off

• Preparation forthe visit

• Practicalinformation forvisits and LinkInduction Pack

• Dos and Don’tsoverseas

• Follow-up aftervisits



Who should be involved?

“There are so many [withinthe hospice movement]who still feel that comingto a Developing Countryto lecture is sufficient.However their lectures arefrequently not suitable toour conditions here. Also,the attitude of “we know itall and are giving it to you”is not accepted too well.”

Dr Anne Merriman,founder of Hospice Africa.

During the initial planning visit(as described in Chapter 2.2),objectives and activities for theLink will have been agreed.These will give the UK partneran indication of the areas ofexpertise needed by theDeveloping Country (DC)organisation. But how do you goabout selecting the appropriatepeople to support the plans?

Recruiting the right people willprimarily be the responsibilityof the UK partner, but it isimportant to share their CVswith the DC partner, who canensure their expertise is what isrequired.

In some cases the appropriateperson to go will be obvious. Inother cases the objectives orwork-streams of the Link maybe broader than the expertise ofthose on the UK LinkCommittee itself. In this case,one option is to openly recruit

interested people from withinthe organisation, creating anopportunity for those with theappropriate expertise to apply.This is also a good way to getnew members of staff involvedand promote your Link.Candidates should beinterviewed and selectedaccording to their suitability forthe work and environment.

In addition to expertise, somepersonal qualities to look outfor in potential candidates are:

• Flexibility to adjust workingarrangements and plansaccording to demand

• Personable, sensitive andopen-minded

• Happy to work in a difficultenvironment

• Accepting of differentcultural practices.

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CASE STUDY

Recruiting for overseas visit participants

“We wanted to make the recruitment process open, to allow new people to be involved with theLink. An email was sent to everyone in the Trust, advertising the Link and the expertise required atthe time. Those who were interested were asked to fill in an application form which detailed theirexperience in key areas: training, teaching experience and overseas work. We got an overwhelmingresponse: over 75 people expressed an interest and 45 submited an application form.

The main advantages of recruiting this way was that we became aware of people who had the skills,experience and passion for this sort of work. Shortlisting and selection was difficult but werecruited both junior and senior staff from various disciplines. We also found that a significantnumber of applicants were willing to pay for all or part of their visit costs in order to be involved.

Of the eight involved in the first year, seven of them have remained very involved in the ongoingdevelopment of the Link as Committee members.

The one mistake that we made was not engaging the unsuccessful applicants in the work of theLink. Maybe we should have been clearer that applicants who were not successful at this stagewould potentially have the opportunity to go later on, or could be involved in other aspects of theLink Committee.”

Dr Dave Baillie, East London Foundation Trust – Butabika Link


2.4

UK


60

CASE STUDY

The benefits of including younger doctors in a visit

Alexander Finlayson and Simon Little, a house officer and asenior house officer from King’s College Hospital, took partin a visit to Link partners in Somaliland. Part of the remit ofthe Link was to work with junior doctors.

“During early years as a doctor it is very difficult to pursueany interest in international health without disruptingtraining. This trip gave just that opportunity”, says Simon.

Alexander agrees, “As house officers we worked closely withinterns, something which was particularly useful as we couldshare our cross-cultural experiences of being a junior doctor.To be surrounded by such an inspirational selection ofcolleagues and students was a real privilege for someone atmy age and stage in a medical career. I have always wantedto pursue a career in academic medicine in developingcountries. This trip has served as a significant boost alongthat trajectory. I have learned about the application ofwestern medicine in a minimal resource environment and therole of innovative idea conception and execution incontributing to medicine in that context. As if this was notenough we also had a tremendous opportunity to learn abouttropical medicine.”

Their work has led to the launch of an e-learning resourcefor interns in Somaliland.

UK

UK

When you are recruiting,remember that:

• The visit will not just be acase of turning up and givinglectures about how thingscould or should be done. It isabout working closely withcolleagues, understandingtheir environment, theirconstraints and supportingthem to make the changesthey want to make.

• It is not always necessaryfor only the most senior staffto be involved. Those at thebeginning of their careersmay have a lot to contributeas well.

• The work of the Link is likelyto involve the whole healthteam (from lab techniciansto hospital managers), soget the most appropriateexpertise to respond to thedemands of the partners.

• Visits should usually beundertaken in teams of 2 to 4people. On the initial visits itis recommended that at leastone member of the team wasinvolved in the initialplanning visit (Chapter 2.2)or has experience of workingin a developing country. Afterthe Link is established, atleast one member of theteam should already befamiliar with the DC partnerto brief the others.

• Each member of the teamshould have their ownindividual objectives.

• Longer visits often have themost significant impact. Ifindividuals with the appropriateexpertise are interested intaking time out (e.g. 3 monthsto a year), this should beencouraged.

• Change happens slowly andthose that are prepared to beinvolved in the Link in the longterm (not just through visits)are most likely to make animportant contribution.

REMEMBER!

Once your Link has selectedpeople with the skillsrequired by the DC partner,share their CVs andapplication forms with yourDC partner to get theirapproval.

Visit duration and time offDuration:For new visitors it takes at leasta week to become familiar withthe environment andunderstand what theircontribution can be. Many findthat a lot of their work takesplace in the second week.Remember you need to factor intime to debrief with partnersand plan for future work. A visitof less than 2 weeks may notalways be appropriate. Theexception might be when theperson or team who are goingare:

• Very familiar with the partnerorganisation

• Going with very specificobjectives and the partnerhas agreed the work can bedelivered in a shorter time

Time off:Some NHS Trusts anduniversities allow staff to usestudy or special leave for Linkvisits. If so, you should havean agreed policy with themanagement on staffentitlements to take paid timeoff. Organisations that do notmake any special leavearrangements for their timeoverseas will jeopardise thesustainability of the Link.If an agreement on leavearrangements is made, bearin mind that different ranks ofstaff may have different leaveentitlements. This may affecttheir ability to get involved withthe Link. If those involved haveclinical responsibilities, locumsmay need to be found, so visitsneed to be planned well inadvance.

DID YOU KNOW?

The Wales AssemblyGovernment instructs allNHS organisations todemonstrate theircommitment to overseasLinks and MillenniumDevelopment Goals byallowing visits, secondmentsand exchanges to be optionsavailable to all the NHSemployees.

See:www.wales.nhs.uk/documents/WHC(2006)070.pdf

Longer visits:DC partners often report thatlonger visits are the most useful,but it is often difficult for UKpartners in full time jobs to getmore time off. Some Linkscombine short, targeted visitswith longer-term placements,where volunteers may go out for3 months or more. Individuals maychoose to do this through a careerbreak or after retirement.


61

CASE STUDY

Study leave processes, the Sefton/Chiro Health Link

Undertaking a 'health needs assessment' to assess theviability of developing a partnership between NHS Sefton andChiro Hospital, West Hararghe, Ethiopia required an overseasvisit of two weeks. Such an organisation-to-organisationpartnership required NHS Sefton to follow internal humanresources processes.

The project was funded by NHS Sefton with support fromTHET’s seed corn funding. It fulfilled the organisation’sexternal training and development policy, particularly inrelation to general career development and fulfilment ofpersonal goals.

2.4

UK

UK


62

CASE STUDY

What can be achieved in just two weeks?

"Sometimes people are sceptical about what can be achieved of real benefit in a two week visit,particularly if it is your first visit. If the visit is properly planned the answer is an awful lot. Youhave to remember that the people working in skilled positions in your partner organisation maybe carrying out multiple roles single-handedly; roles which would be carried out by a team ofpeople in the UK. They may, for example, be well capable of carrying out specific periods oftraining for their own staff, but because of their workload, just do not have the time.

People from the UK can provide short periods of very necessary training in a variety of subjectareas, as long as they are ready to undertake such tasks immediately following arrival and areable to complete the task prior to their departure. All this takes planning and the establishmentof regular communication between the UK and the overseas hospitals.

The resources necessary to transfer a small team to your partner organisation can beconsiderable, so it is important to make it worthwhile! Talk, plan and prepare. "

Dr Ian Holtby, involved in the Middlesbrough-Lilongwe Link

Planning forthe visit

Before arrival

DEVELOPING COUNTRY PARTNER

• Share details of the planned visit withcolleagues throughout your organisationincluding the Director’s office.

• Discuss the best use of the visitors’ time.

• Ensure that staff who will be involved intraining from the Link partners areinformed at least two weeks before thevisit takes place and take measures toensure that people can attend.

UK PARTNER

• Spend time talking to some of the peopleyou will be working with overseas.Exchange emails or talk on the phone.

• Share objectives and the activities of yourvisit, along with your dates of travel withthe UK Link Committee and colleaguesoverseas.

• Your visit will form part of a previouslyagreed objective or workstream of theLink. Make sure you are familiar with whythese areas have been prioritised, whatvisits (if any) have taken place in the pastand speak to those who have beeninvolved previously.

DC UK

Preparation for the visit

It is important to plan well in advance of a visit, ideally at least 3 months. Objectives will have been set for thevisit but you will need to agree on activities and plan them. Here are some tips on planning:

Planning checklist for visits to the DC organisation

• Build on the work of the previous planning visits (see Chapter 2.2). Review objectives andagree activities to be carried out during the visit. Put these down in writing and sharethem.

• Agree on an appropriate time for the visit to take place that suits both your timetables anddoes not coincide with a busy time when everyone is tied up in other work. Avoid religiousfestivals, public holidays and exam times.

UK


63

2.4

Planning checklist for visits to the DC organisation

Before arrival

On arrival

Planningworkshopsand training

Feedback onvisit andfutureplanning


• Communicate with your partners and letthem know what exactly you will expectthem to do – ideally with a timetable thatthey can feed into – so they can prepareadequately.

• Arrange accommodation for the visitors– ideally in a guest house close to yourorganisation. Inform colleagues whenyou have done this.

• If colleagues are arriving at an airportclose to your organisation, arrange tohave a vehicle meet them on arrival.But if the airport is some distance awayinform them of the best way to reachyou (e.g. taxi and bus) with directionsand ideal times of travel.

• Once they arrive, arrange for them tomeet key people and become familiarisedwith the organisation.

• Review the objectives of the visit, thetimetable of activities and ensure thatyou agree and that they are realistic.

• Remind people about any activities theywill be involved in and the times of anyformal trainings to ensure that theyattend.

• Help visitors prepare any handout notesor any stationery they need.

• Work with partners to discuss whatteaching methods will be the mostappropriate.

• Discuss feedback forms and othermonitoring methods you are going to use.

UK PARTNER

• If your Link has a pre-departure inductionmeeting make sure you take part in this.

• Ensure that all participants sign anydocuments that are a requirement forundertaking visits as part of the Link.

• If you are being collected, make sure youhave the person’s contact details in caseyou can’t find them on arrival.

• Appoint one member of the team as thevisit leader. They can act as the mainpoint of contact and should keep note ofany general issues about the Link raisedduring the visit.

• Have the address of your partnerorganisation to make your own way therein case of emergency.

• Prepare to be flexible and adapt alongthe way. Things do not always go to plan.

• Be ready to listen to your host,acknowledge what inputs they makeand how the prepared objectives/activities will be best carried out.

• Conditions on the ground may be verydifferent to the scenarios constructedfrom previous correspondence.Be prepared to be flexible.

• Support rather than direct.

• At the end of each week make time to review what has been done so far, what has beensuccessful and what has not worked so well

• Use the planned outcomes as a basis for evaluating the visit and learning for the future(jointly with your partners)

• Discuss how to take work forward

• Agree and plan future activities

DC UK

Practical information for visits and Link Induction Pack

Each Link should have its own Induction Pack which is updated on a regular basis and provides specificinformation to visitors. Once the Link is established, the Induction Packs should provide all the informationnecessary to plan a visit. For new Links and those developing Induction Packs, the following table has someuseful advice:

Contextassessment

Riskassessment

Passports

INFORMATION

You will need to have anunderstanding of thecontext in which yourpartner or potential Linkpartner works in order tohave an understanding ofthe operatingenvironment. This is tominimise risk as well as tosee how you are best ableto engage with yourpartner.

The risks in anenvironment are afunction of both thecontext and the role youand your partners areperceived to play in it.Accurate risk assessmentallows you to prepare forand mitigate against risks.This both reduces thelikelihood of being exposedto a particular threat, aswell as helping you to dealwith it should the riskoccur.

You will need to check wellin advance that you have afull, valid passport with atleast three months validity.If a visa is required you willneed at least one blankpage remaining.

TIPS

• Check with local partnersand international NGOs forcontextual information.

• Websites such as FCO, CIAfactbook, Reliefweb, ReutersAlertnet and other news sitesare good sources of up-to-date contextual information.

• Ensure that partners will givea contextual briefing onarrival.

• THET’s Risk and SecurityGuidelines for THET staff andLinks give details of how toconduct a risk assessment.

• Inform your insuranceprovider of risk assessmentprocedures. This cansometimes reduce yourinsurance premium.

• Ensure staff are aware of therisk environment they areentering, and know whatmeasures to adopt.

• You can check the entryrequirements of the countrythat you are travelling to onthe FCO websitewww.fco.gov.uk.

• The FCO website alsoprovides useful informationfor what to do if yourpassport is lost or stolenduring your visit.

• Scan or photocopy yourpassport and either email itto yourself or give it to acolleague. If your passportgoes missing this will make iteasier.

TO INCLUDE IN THEINDUCTION PACK

• Give a summary of contextualinformation in the InductionPack, to include geopolitical,historical and economicinformation, as well asbackground to any conflictdynamics.

• Complement this writteninformation with apre-departure and arrivalcontextual briefing.

• Give an overview of riskassessment within theInduction Pack.

• The Induction Pack shouldlist the most prevalentthreats identified by therisk assessment along withmeasures to mitigate.

• Include a security overview/advice pack.

• Tell staff if the country theyare travelling to requirestheir passport to be valid fora certain period of time afterthe trip or have a certainnumber of blank pages in it.

• Include information in theInduction Pack about whatstaff should do if theirpassport goes missing.Include contact numbers forthe British Embassy in thecountry.


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2.4Visits to theDeveloping CountryOrganisation

UK

Passports

Visas

INFORMATION

To enter most countriesoutside the EU you willrequire a visa. Notableexceptions are: Malawi,South Africa, Gambia andBotswana, but checkbefore travelling. You maybe able to get a visa onarrival, usually payable inUS$, or you may berequired to get it inadvance from theembassy. UK nationals arerarely rejected in responseto a visa application, butthe process could takeseveral weeks (and requireyou to submit yourpassport) so plan inadvance. Some travelagencies can arrange thisfor a fee. If you have thechoice of getting the visaon arrival (e.g. Uganda,Ethiopia) this is usuallyeasier and sometimescheaper.

TIPS

• If you are going to apotentially dangerous area,it might be worth registeringyour trip with the BritishEmbassy in country (orrelevant embassy for non-UKnationals). Where a BritishEmbassy is not present, allEU countries have reciprocalarrangements with eachother, so registration atanother EU embassy wouldbe possible.

• You will often be given atick-box option to choosetourist or business visa.A business visa is for anyindividual undertakingbusiness or any work (thisusually includes voluntarywork).

• If your Link travels overseasmany times a year you maywant to develop arelationship with the embassyof your partner’s country.Inform them of your work,share MoUs and they maygrant you free visas.

• Some countries, such asMalawi, have an exit fee.Ensure you have enoughmoney set aside for this.

• Consult the embassy websitefor details on obtaining visasand costs. The Foreign andCommonwealth Office (FCO)website provides contactdetails for all foreignembassies in the UK, bothin London and outside:www.fco.gov.uk/en/about-the-fco/what-we-do/building-strong-relationships-ol/foreign-embassy-uk


• Provide information onwhether a visa is needed,the best way to get it andhow much it costs.

• Have copies of the visaapplication form accessible.

• If you have a specialarrangement with theembassy, let people knowwhat they need to do to getthe visa.

• Provide embassy informationand contact details.

2.4


65

2.4Visits to theDeveloping CountryOrganisation

UK

Bookingflights

Injectionsandprophylaxis

INFORMATION

As money for flights willgenerally come fromfundraising activities usingpublic funds, it isimportant to get the bestdeals. Book in advance,and search around for thecheapest flights. Avoidpeak seasons, such as theend of December and Julyand August which tend tobe more expensive.

Ensure that yourimmunisations are up todate and appropriate forthe country you arevisiting. The nurse at yourGPs office will be able totell you what you need.The full range of injectionscan be a significantexpense so ensure thatyou are clear who ispaying for this. Has yourLink agreed to cover thisor will you pick up thecost?

In a malarial area,prophylaxis isrecommended. There aremany different drug typesto choose from – getadvice from your GP.Barrier prophylaxis suchas mosquito nets andrepellent should be usedin conjunction withantimalarial drugs.

TIPS

• Check out travel comparisonwebsites such aswww.travelsupermarket.comfor the best prices.

• When booking flights checkif it is a flexible fare, allowingyou to change the dates ifnecessary, or if you can geta refund if the visit can’t goahead.

• Some specialist travelagencies can occasionallyoffer discounted tickets andextra baggage allowance.See www.keytravel.co.uk.

• Visit your GP for yourinjections –they can providesome injections free ofcharge while a travel clinicwill not.

• Many injections may needto be given up to 2 monthsin advance to be effectiveso don’t leave it to the lastminute!

• Injections such as rabies areoptional. If you are workingin a hospital setting you maynot need this.

• Some countries may requireyou to show your yellow fevercertificate on entry. It is validfor 10 years so ensure youkeep it safely. If you have lostit you may be able to get yourpractice to re-issue acertificate.

• Some antimalarial drugsrequire you to starttreatment a few weeks beforedeparture, so plan in advance.This will also allow you to seeif you suffer from anyadverse side effects.


• Give a guide on how muchflights should normally cost.

• Provide details on thebooking arrangements –should the individualtravelling do it or will theLink coordinator arrangetravel?

• Ensure that differentmembers of the team alltravel on the same flights.

• Include specific advice onwhere to check for flightsand who should beresponsible for purchasingthe ticket.

• Ensure you have a policyon who pays for injections– is it the individual, the Linkor a shared cost? Bear inmind that many injectionslast for several years andthose who are well travelledare likely to already have thefull range of injectionsneeded.

• Have a Link policy aboutwhether optional injectionssuch as rabies are necessary.It is expensive and is onlyrecommended for thosetravelling to endemic areasor those who will be basedin remote areas.


66


UK

Health andSafety

Money

INFORMATION

Most trips run smoothlyand your partnerorganisation is likely todo everything possibleto make your stay anunforgettable experience.However it is important totake some precautions justin case and ensure not toput yourself atunnecessary risk.

Carry a mixture of cash(£ and US$) and creditcard with you – but if youare based in a rural areado not rely on your creditcard. Travellers chequesmay be an option if youare taking large amountsof money, but they areoften more complicated tochange and have a lessfavourable exchange ratethan cash.

For an average 2 weekvisit it is unlikely that youwill need more than £400spending money. You arelikely to be staying incheap accommodation, orbe put up by the partnerhospital, and be eating inlocal restaurants.

TIPS

• Be sensible but not neuroticabout the food you consume.Try to drink only bottledwater and do not eatreheated food.

• Take the necessaryprecautions in hot climates.Drink lots of water.

• Consider the risks you mayencounter and how to reducethese, see Chapter 2.1.

• In most countries £s are aseasy to change as any othercurrency, although you mayneed some US$ for on-arrivalor departure visas.

• Depending on the country,reasonable expenses may bearound £20-£25 a day plusadditional visa and travelcosts, such as internal flights.

• Some countries have officialand unofficial exchange rates;find out where to get the bestdeals.

• If expenses are going to beclaimed back, it is essentialfor travellers to keep receipts.


• Have HIV PEP packs/ 1st aidkits for staff to take if theyare likely to be at risk.

• Ensure that the LinkCoordinator is signed upto FCO updates for yourpartner’s country to be upto date with security issues.

• Ensure that your Link hasconsidered risk and duediligence issues (seeChapter 2.10)

• Where possible provideinformation onrecommended local bus, carhire, taxis and in-countryflight information.

• Have a policy on what costsare covered by the Link andwhich ones aren’t:expensive hotels/ first classtravel/ alcohol?

• Tell visitors how visitexpenses should beaccounted for. Do staff needto record and keep receiptsfor all expenditures?

• You may have differentpolicies for different staffmembers e.g. higher paidstaff members cover owncosts, while lower paid oneshave costs subsidised.

• Information on best placesto change money while incountry.

• Precautions to take whencarrying money.

2.4


67


UK

Baggage andwhat to take

Insurance

INFORMATION

Find out from Linkpartners and previousvisitors what isappropriate clothing andwhat you need to take.

You will usually be able topurchase any personalitems you need overseasand the lighter you travelthe better. Remember toleave room for books,teaching equipment andresource material for yourpartners.

Differing types ofinsurance will be requiredwhen conducting visitsoverseas. For nursesregistered with the RW,indemnity and liabilityinsurance gives worldwidecoverage.

Doctors are advised tocontact their ownprofessional insurancecompany (MDU or MPS).

Appropriate travel andmedical insurance that willcover the visit is required.See Chapter 2.11.

TIPS

• Find out what the airlinebaggage allowance is. Thestandard allowance is 25kgalthough some airlines e.g.Ethiopian Airlines givearound 45kg – this will allowyou to take additional booksor equipment with you.

• You may want to take alaptop to write up your workwhile there and prepareteaching and handouts.

• Contact your currentprovider of indemnityinsurance prior to the trip.

• Consider taking out aWorldwide group travelinsurance policy to coveryour Link for visits andplacements overseas.

• Take out a group medicalinsurance policy that willcover your Link for visits andplacements overseas.

• Having appropriate riskassessment procedures inplace can reduce yourinsurance premium (see riskassessment section above).

• Some countries are excludedfrom most worldwideinsurance packages.These are usually linked toFCO advice. Check with yourinsurance provider and FCOwebsite for potentialexclusion areas.


• Give guidelines onappropriate clothing,equipment to take and anynecessary items that cannotbe bought locally.

• Provide information onlimits to baggage allowanceand excess charges thatmay apply.

• Provide information on anyimport restrictions onparticular goods.

• Have a policy on insuranceand a trusted supplier. Ifvisitors have their ownyearly insurance policycheck that it provides theappropriate cover. Refer toChapter 2.11 for furtherinformation.

• Induction Packs shouldremind participants of theneed to contact theircurrent provider ofindemnity insurance.

• Give details of travel andmedical insurance coverand conditions

• Give details of main risksassociated withcountry/region of visits,along with mitigationmeasures.

• Prepare quick referencecards as part of theInduction Pack, to includeinsurance details and keycontact numbers andprocedures.


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UK

Communi-cation

Accomm-odation

In case ofemergency

INFORMATION

Any sizeable town is likelyto have an internet cafeand you may be able toaccess it at your hostorganisation. But powershortages and slowinternet speeds mayinterrupt you.

It is a good idea to have alocal mobile phone. Allyour partners will have oneand it will allow them tocommunicate easily withyou.

Get your DC partners toarrange this for you ormake a recommendation.

Most trips run completelysmoothly but it is better totake some precautions incase of an emergency.

If you lose your passportthe process of getting anew one will be made a loteasier if you know thepassport number. Report itlost or stolen immediatelyand the Embassy or HighCommission will be able tohelp you to get areplacement.

If an accident or emergencyoccurs, it is important toknow who to contact andthe steps to take.

TIPS

• Get a mobile phone that isnot locked to a network andbuy a local sim card. In mostcountries they are cheap andeasily available and you willhave a variety of networks tochoose from.

• Pass the sim card on to thenext set of Link visitors. Bearin mind the cards often onlystay active for between 1-6months when not in use soconsider lending it to a localfriend to keep it active inbetween visits.

• Much of the anglophoneworld has the same electricalplugs as the UK so you maynot need an adaptor plug.Load shedding may meanthat there is not alwayselectricity though!

• Constantly back upinformation on laptops andcomputers on flash drives.

• Leave-in country contactdetails with friends andfamily at home.

• Remember that your Link isusing public funds and youcannot justify staying in themost expensiveaccommodation.

• Give a copy of your passportto your Link coordinator andkeep a photocopy yourself.You can even scan it in andemail it to yourself.

• Have an establishedemergency procedure tocover potential scenarios.

• Ensure you know your bloodtype and that someone onyour team is also aware.


• Have a policy on how andwhen visitors should makecontact. Who will be thecontact person? Have anall-hours number in caseof emergency.

• Have a mobile phone andsim card for the Link so thatvisitors can be contactedwhen needed.

• Copy of contact numbersin UK as well as contacts inDC should be left with thefamily/friends before thevisit by the Link visitors.

• Include tips onrecommended hotels/ guesthouses, price guides, etc.

• Have an agreed emergencyprocedure which your Linkstaff should adhere to.

• Include a list of in-countryemergency contact numberssuch as the HighCommission, local hospitalscovered by insurance, otherlocal contacts, etc.

2.4


69


UK

Professionalregistration

INFORMATION

If you are going to bedoing hands-on workcheck whether you willneed to register with theprofessional registrationauthority and whetheryour insurance covers you.

Most countries have theirown professionalregistration authoritiesand you may be requiredto obtain registration inthe host country beforebeing able to engage inany form of clinicalpractice. Where there is noregistration system it isusual for UK professionalregistration to be valid.

You will need to practise inaccordance with the lawsof the country to whichyou are going.

TIPS

• Contact the Ministry ofHealth about this, yourregulator in the UK or theProfessional Bodies.Alternatively speak to otherLinks who have been involvedin similar work in yourpartner country.

• Inform your current providerof professional indemnityinsurance prior to departure.

• Verification of registrationmay be needed. Yourprofessional registrationauthority can provide this.You should contact them wellin advance to obtain this andthey may charge a fee.


• Consult with your overseaspartner as to whether in-country registration withthe professional registrationauthority is required, and ifso include information onhow this can be done.

• Include information aboutwhether verification of thisis needed.

• For non-English speakingcountries it may benecessary to haveprofessional registrationdocuments translated inadvance.

• Include information aboutany codes of practice thatapply and any limits topractice.

Dos and Don’ts overseas in the DCRemember that when you are overseas you are an ambassador for your Link and the UK.Ensure that you conduct yourself in a respectful way. Most of this is obvious but....

DO...

Be aware that English is likely to be a secondlanguage for many colleagues overseas. So if youare giving a talk or lecture remember to:

• Speak slowly and clearly

• Produce handouts or visual aids to accompany anyclasses you teach. (Consider taking CD-ROMs withyou rather than allowing others to download filesfrom your computer to a memory stick ascomputer viruses are a major problem).

• Do not use jargon as this may not be understood.

• Where possible choose to work in smaller groupsas it will be easier for people to follow.

• Teach any classes in conjunction with a localcounterpart, and they can help you understandthe best ways to engage students. Local input alsoprovides valuable insight into local contexts bothin terms of presentation and management ofdisease.

• Make an effort with the language and learn basicgreetings.

DON’T...

Be critical of cultural differences in the treatmentof patients, even if they are difficult or unfamiliarto you. For example in the UK, illness is a privateaffair and so confidentiality is of utmostimportance. A visitor overseas may be surprisedthat this is not maintained to the same degree andwant to encourage it. In some cultures privacy maynot be held in such high regard and people do notmind sharing their problems more widely, or evenexpect to share things in a group. There may alsobe logistics to consider; if staff are short, a groupconsultation may be the only option.

70

2.4Visits to theDeveloping Country0rganisation

UK

Dos and Don’ts overseas (Continued)

DO...

Make an effort to build friendships with colleaguesoverseas, and spend time getting to know them andthe local environment. Exchange contact details andcontinue to communicate in between visits. Takingphotographs of your family with you can be a usefulicebreaker and identify your personal role as well asyour professional one.

Get a briefing from your local partner and other keycontacts on arrival. Do some research on where youare going. Use resources such as

• www.fco.gov.uk/en/internet resources

• www.cia.gov/library/publications/the-World-factbook

• www.reliefweb.int/rw/dbc.nsf/doc100? OpenForm

• www.alertnet.org

You may also wish to contact local diaspora groups.

Provide certificates for any training or new skills.In many countries, certificates are very importantand it will help with morale. If your training doesn’tfit in to any other formal arrangements you canproduce certificates yourself with the Link logo on it.

Be aware of cultural differences and norms.For example in a Muslim country it may not beappropriate for men and women to shake hands,and women may be required to wear head scarves.People tend to be formal in work contexts. Hierarchyis often also very important, so find out who youneed to pay courtesy visits to at the beginning.

Ask colleagues to provide feedback on your work,what aspects have been particularly useful, and whathas not been so good. This will help you to planbetter for the future. Student and trainee feedbackis as important as senior colleagues’.

2.4

DON’T...

Criticise your partner organisation or the workof colleagues overseas. They often do acommendable job within the available resources.This does not mean that you should not advocatechange and change is not possible. See Chapter 2.7for more on identifying and overcoming barriers tochange.

Get disheartened. It is sometimes easy to feel thatyou and the Link are not making any difference atall. In truth the Link is unlikely to be able to turnyour partner’s difficulties round even in a fewyears. The Link is only a small factor in a complexweb, but your encouragement and motivation isimportant. Ensure that monitoring and evaluationare undertaken as part of the Link work as this willhelp you to understand the differences you aremaking.

Emphasise your holiday. If you are planning toprolong your stay after your visit be careful not tooveremphasise this, as it could be seen as the onlyreason why you are visiting.

Make promises you will not be able to keep.This will raise expectations and causedisappointment when you have not been able toachieve these.

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FIND OUT MORE

THET has producedguidelines for ethicalconsiderations when takingphotographs as part of yourLink. You can find these onTHET’s websitewww.thet.org.uk

Follow-up after visitsA single Link visit, on its own, isnot likely to produce long-termand important changes. It will needto be integrated into a series ofactivities agreed by both partnerswhich will contribute towards theachievement of a Link objective.

At the end of the visit you willneed to jointly reflect on what hasbeen achieved and what furtheractivities the Link needs to deliver.This may include further exchangevisits, mentoring, support orequipment provisions.

The follow-up reportIt will be important to compile avisit report, both for the purposeof sharing information within yourLink and for monitoring purposes.If possible, this should be jointlyowned by UK and DC partners.You might want to develop astandard report format for all yourLink participants to use. All visitorswill need to produce a report.

It will also be important to sharevisit reports with overseascolleagues and other members ofyour Link Committee. Encouragethose who have been involved invisits to give verbal feedback tothe Link Committee and beinvolved in future planning of theLink. The end of a visit should notbe seen as the end of the work.Indeed it confers particular

responsibilities on you to sustainthe work that has been generatedby the visit.

REMEMBER!

Draft the report very soonafter, or, even better, duringthe visit and journey back –otherwise it can so easily getgrossly delayed as normal lifepressures reassertthemselves!

Refer to Appendix 7 for a samplereport templates

Useful headings for your reportmight include:

• Brief description of the Link

• Overall objectives

• Background to visit

• Visit objectives

• Activities undertaken (factualsummary with dates)

• Results (data including numberand names of people trained;analysis of pre and post testresults) see M&E Toolkit forfurther information (p89)

• Were objectives achieved?

• Barriers or problemsencountered

• Lessons learned

• Future objectives, planningand responsibilities.

Think about what follow up isneeded: it may be appropriate fora colleague from your Link partnerto come for training in the UK, orperhaps another visit is needed tofollow up on the work in 6 monthsor 1 year’s time.

Mentoring and communicationshould take place between visitsand colleagues will appreciatecontinuing communication withyou so that they can feelsupported. If you do not follow-upwith colleagues overseas it willcause disillusionment and undoany good work that was doneduring the visit.


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/

!


73

2.4

CASE STUDY

Health Link Malawi's debriefing process

“When staff return from visits to Malawi we offer each team member a post-placement healthcheck and debrief.

During the debrief we encourage people to talk about their experience of the visit, both negativeand positive. The feedback is used to inform and improve preparation for future groups. Inaddition, if any emotional support is needed we can refer them to the appropriate person.

This need arose from one of the first groups to go out in 2006/7 which comprised two midwiveswho had not previously encountered such high levels of maternal death. This identified thatpsychological preparation is vital to ensure that staff get the most from their placements as theywill encounter significant cultural and health-related differences. Our experience has shown thatwhen some group members do not know each other before spending 3 weeks in close proximity,having a chance to meet socially prior to travel can make a real difference to team bonding.

The debrief process also involves identifying any health issues that occurred whilst on placement,e.g. Illnesses, use of HIV PEP pack, and ensuring any health surveillance is carried out where riskshave been identified, e.g. schistosomiasis.”

Jude Rowley, UHCW for Health Link Malawi

CASE STUDY

Keeping up the momentum after visits

“The return journey from a visit to a Link hospital can be an exhilarating experience, particularlyif this has been a first visit. Working for a short while in a different environment, meeting newpeople and taking in a new perspective on health care can help stimulate the creation of a listof good intentions, things to do on return to UK to help our African Link partners.

Then comes the return to work, the backlog of things to get through. The visit to the partnerhospital becomes a distant memory and the need to carry out those promises becomes lessthan pressing.

You should try to avoid this situation; it will slow progress of the work and let partners down.When the next visit to the Link hospital finally comes round, little will have been done, which willdemoralise you and your partners.

It is important to establish a realistic timetable of actions needed on return to UK.Communication, support and mentoring in between your visits will be as important to colleaguesoverseas as the visit itself. Before you leave agree with colleagues what the best way tocommunicate with them is. Make sure you send them a copy of your visit report, your agreedactions, and continue to communicate and see how the work is going.”

Dr Ian Holtby, involved in the Middlesbrough-Lilongwe Link

UK

UK

} CHAPTER CHECKLIST

} Start planning the visitwell in advance – at thevery least 3 monthsahead.

} Discuss with your DCpartner the objectives ofthe visit and whether theywould benefit from senioror junior staff, newvisitors or continuity ofLink members.

} Have agreed and a writtendown set of aims andintended outcomes forthe visit.

} Decide who will be goingon the visit – considercarrying out an openrecruitment process.

} Take out appropriatemedical & travelinsurance, or ensure thatindividuals have adequatecover. Ensure that staffinform their currentprovider of indemnityinsurance of the trip.

} Create an Induction Packfor staff going on the visitincluding:

• Practical advice forplanning the trip.

• Terms of Referenceand Link Policies.

• Contextual & RiskAssessment.

} Discuss cultural dos anddon’ts with staff beforethey leave.

} Create a post-visit reporttemplate for returningstaff to fill in and hold adebriefing session tocollect feedback andupdates. Write visitreports during visits andon the way home so theydon’t get delayed.

} Evaluate the outcomesof the visit and learn thelessons.

2.4Visits to theDeveloping Country0rganisation

74


The main currency of a Link isnot money, but SKILLS. Andeach shared skill is a long-termasset for development.

2.5 Visits to theUK organisation

76

Targeted training visits for selectstaff from the Developing Country(DC) organisation to the UK canhelp provide new ideas, developthe partnership and motivatepeople.

In order for the visits to have awider impact they need to becarefully planned and involvethose who can adapt the ideas andsystems they see in the UK to thelocal context in which they work.

This Chapter addresses issues forthose planning and undertakingvisits to the UK and covers issuesrelevant to both the UK and DCorganisation.

In this Chapter...• When are visits to

the UK a good idea

• Who should beinvolved

• Visit durationand time off

• Preparation forthe visit

• Practicalinformation andLink Induction Pack

• Dos and Don’ts inthe UK

• Follow-up aftervisits




77

When are visits to the UKa good idea?

“One of the most importantthings I learnt from myvisit was that we could dobetter. The Link allowed usto see ourselves in a mirror,and gave us theopportunity to pick andadopt the structures, skillsand procedures that arerelevant to us.”

Hamidu Abdulai,pharmacist, Tamale Hospitalin Ghana.

Visits to the UK inevitably costmore due to higher living costs.Fewer individuals from the DCorganisation benefit directly fromtraining and therefore some Linksquestion if this is the best use ofresources.

Those individuals involved inexchange visits to the UK willonly have a wider impact on theirorganisation if they are ableto draw on the knowledge andexperiences in the UK and adaptthis to their work. If the rightpeople are selected to be involvedin the visits with well definedobjectives they can have asignificant impact and alsostrengthen the understanding andcommitment between partners inthe UK and the DC. It can also havea significant impact on morale andmotivation of DC organisationstaff, where there they may feelvalued and supported in theirwork.

Visits to the UK are mostappropriate when the Link istrying to develop new serviceswhich are not available locally orstrengthen existing ones. Exposureto a UK health care environmentcan provide new ideas which canbe adapted to the local context.

Visits to the UK should be signedoff by the head of the DC partnerorganisation. Bear in mind the riskof losing staff to the brain drain ifvisits are not carefully justifiedand well planned.

REMINDER!

While in the UK it is usefulto try and find any relevantconferences, professionalbodies, etc which you maybe interested in attending.

2.5

DC

f CASE STUDY

Training in the UK

Two senior mental health nurses from Zomba Mental Hospitalin Malawi participated in a Link training visit to gain skills innon-pharmacological interventions in the UK. The activepartnership between the Department of Health Sciences atUniversity of York and the Zomba Mental Health Link enabledthe nurses to enrol as guest students and attend a module onpsychosocial interventions for patients with psychosis.

The nurses were able to access the taught component ofthe course, as well as the library, IT resources and tutorialsupport. The focus was on patient-centred and familyapproaches. The two Malawian nurses found that it wasreadily applicable to their work in Zomba. They also madea significant contribution to providing UK students with awider cross-cultural perspective on their clinical work andenvironments.


78

Who should be involved?The initial planning stages ofthe Link (Chapter 2.2) will haveidentified priority areas whichwill be the focus of the Link.Visits to the UK might be themost appropriate way ofaddressing some of these areas.Sometimes the people involved inthe visit to the UK will be obvious:there may be a limited number ofpeople who do a particular job orare enthusiastic or motivated totake the work forward. When thereare several potential candidatesthere will need to be an openrecruitment process which willprimarily be the responsibilityof the DC organisation.

Some personal characteristicsyou may want to look out for are:

• Committed individuals – theyhave shown strong commitmentto the organisation, thedepartment and the patients/students, have a life in thecountry and no strongaspirations to work/ live inthe UK

• Problem solvers - they are ableto see solutions to problemsand overcome them rather thanbecoming disillusioned

• Enthusiastic and adaptableindividuals

REMEMBER!

Those involved in trainingvisits to the UK should beselected on the basis of whatthey will be able to contributeon return to the organisation,not on personal ties orbenefits. The head of the DCorganisation should approvesuch visits personally.

Visit duration and time offWhile visits from UK partnerstend to be of around 2 weeks,many visits from DC partners tothe UK tend to be for slightlylonger periods (an average of 4weeks but some have been up to6 months). This is because thoseinvolved will need to adapt andabsorb as much as possible fromthe learning opportunitiesavailable to them.

The visit duration will bedetermined by the activities tobe carried out in the UK and theability of DC staff to continue thework of the health workers whoare away on training visits.

REMEMBER!

There is often an opportunitycost of external training forhealth workers. Will their gainin knowledge and subsequentimprovements in practice besufficient to justify the timespent away from the clinicalsetting?

!

DC

f CASE STUDY

Training in the UK

Sometimes the relevance of training in the UK is questioned. Only a few people can be involvedfrom the DC organisation and they will be unlikely to be able to do any hands-on work. Thecontext is also very different. Will there be any lasting impact back at the DC organisation?If the right people are chosen and receive the right type of exposure in the UK and supportupon their return, the impact of the visit may be significant. This impact may not always berelated to the direct objectives of the visit.

Elias Byaruhanga, a Psychiatric Clinical Officer from Uganda, says “What I noticed in theUK was how health care was centred on the patient. Everything about their condition, thetreatment and their options was explained to them. Because of this they understood better andleft feeling happier. I realised we didn’t do that in the same way, but it would be easy to changeour practice. I now take time to explain things better to my patients and their carers as well asencouraging colleagues and students working with me to do the same. They get a better servicenow because of it.”

Dr Margaret Mungherera, Consultant Psychiatrist, Uganda, says “At the time I went to the UKwith the Link through THET, I had just finished my training in Psychiatry. As there were noForensic Psychiatrists in Uganda at the time, I was selected to go to the UK to do an eight weekforensics placement. What I learned in the UK has helped me in my career and to improve thehealth services for mental health patients in Uganda. On my return I was given soleresponsibility for designing the new forensic unit of Butabika Hospital in Kampala, for whichI drew on my experiences from the UK. Butabika Hospital had no clinical psychologists orpsychiatric social workers at the time I left for UK. I had heard and read about the multi-disciplinary care but I had never seen it practiced; I therefore only knew it in theory. In the UKI saw how this worked and was able to integrate it into our work. I saw the need to involvenurses in the Link to train them in modern skills of psychiatric nursing, and this is what we did.And later I worked with THET to develop a project for in-service training of nursing and otherstaff. I was also able to make a useful contribution to the Ministry of Health concept paperjustifying the need for a Mental Health Act based on knowledge from the UK. My shortexperience in the UK helped me to bring about many changes in forensic psychiatric servicesin Uganda.”


79

2.5


80

Planning forthe visit

Before arrival

On arrival

Learning andtraining

Feedbackon visitand futureplanning


• Ensure that you have all the requiredpapers for release from your organisation,have arranged your visa and have a validpassport.

• Liaise with your UK partner for travelarrangements and who will meet you onarrival.

• Ensure you have enough money and atleast two contact numbers and an addressin case you can’t find the person to meetyou at the airport.

• Be aware of what arrangements have beenmade to collect you from the airport. If youneed to use public transport get preciseinstructions.

• Take notes. These will be invaluable to jogyour memory back at your place of workand for sharing your learning withcolleagues.

• Ask as many questions as possible. Don’tbe shy, this is what the visit is for and it willalso show your enthusiasm.

• Always be on time for meetings and otherarrangements!

• Be ready to support your UK partners bymeeting their colleagues and managers –you are an important advocate for thevalue of the Link!

UK PARTNER

• Find suitable accommodation for thevisitors. This may be in staff/ studentaccommodation or some Links haveinvited visitors to stay in staff homes.Hotels often tend to be too costly.

• Inform all relevant people.

• Arriving in the UK for the first time canbe very daunting, especially at busyairports. Make sure that someone is thereto meet your visitors, take them to theiraccommodation and make sure that theysettle in.

• If the Link is providing visitors with perdiem allowances, make sure that they areaware of this on arrival. Most Links haveprovided around £100 a week to coverfood and other expenses, in addition toaccommodation.

• Ensure that visitors receive an inductionto your organisation, meet all the relevantpeople and have some social activitiesplanned.

• Review training with partners on aregular basis to ensure that it meets theirexpectations and make any amendmentsto plans if necessary.

Preparation for the visit

Planning checklist for visits to the UK organisation

• Establish exact objectives for the visit. Discuss these with your partner. The UK organisationshould develop a visit timetable. Inform all the relevant people, especially managers anddirectors, of the training visit. Get written agreement from the head of your organisation.Look into any relevant conferences or relevant short courses which could also be combinedwith the visit.

• At end of visit the UK partner should, if possible, accompany the DC visitors to the airportand see them safely through to the departure lounge.

• Jointly plan the future and set your future targets.

• Take copies of any learning or training materials back with you.

DC UK


81

Contextassessment

Riskassessment

Passports

GENERAL INFORMATION

• You will need to have an understandingof the context in which your UK partnerworks in order to have an understandingof the operating environment at theorganisation.

• Ask your UK partner for information.

• The BBC website is a good source ofinformation on UK events www.bbc.co.uk

• Ask your UK partner to give you acontextual briefing on arrival.

• In order to minimise risk ask your UKpartner to provide an overview of securityissues.

• THET’s Risk and Security Guidelines forTHET staff and Links give details of howto conduct a risk assessment.

• Ensure staff are aware of any risks in theenvironment they are entering, and knowwhat measures to adopt.

• You need a valid passport with at least sixmonths validity remaining to travel. If youdo not already have one you will need toarrange this well in advance. You will alsoneed a visa.

TIPS AND ADVICE FOR INDUCTION PACK

• Give a summary of contextualinformation in the Induction pack, thisshould include a guide to the local areai.e. What are the demographics like, is itan urban or rural area? Are there anyparts of the local area that have a highcrime rate?

• Although the UK is a stable country,certain areas, in particular inner citiescan have areas that are unsafe at night.

• Give an overview of risk assessmentwithin the Induction Pack.

• Induction pack should list the mostprevalent threats identified by the riskassessment along with measures tomitigate.

• Accurate risk assessment allows you toprepare for and mitigate against risks.This both reduces the likelihood of beingexposed to a particular threat, as well ashelping you to deal with it should the riskoccur.

• If you are planning to travel apply fora passport as soon as possible.

Practical Information and Link induction PackEach Link should have its own Induction Pack which is updated on a regular basis and provides specificinformation to visitors. Once the Link is established the Induction Packs should provide all the informationnecessary to plan a visit. But for new Links and those developing Induction Packs, the following table hassome useful advice:

2.5


DC

Visas

Bookingflights

Healthand safety

Money


Ask your UK partners to write you a letterof invitation in order to support your visaapplication. In it they will need to state:

• Reasons for the visit

• Who is funding it

• What the visit duration is

• State that this is part of anorganisational Link

They should write it on headed paper fromtheir organisation and send a copy to youand another copy directly to the HighCommission/Embassy.

If possible try to arrange your time of traveloutside the popular holidays of Christmasand Easter. This will often mean cheaperflights and more people around. Prioritisealso the warmer summer months as this willmake the visit more enjoyable.

Charity travel agent KeyTravel occasionallyoffers competitive flexible flights forcharities with extra baggage allowance anddate changes. Check with them to see howthe rates compare.

• Ask your UK partner to inform people ofany relevant checks they will need toundertake.

• Ensure that you have some money withyou (at least £100) on arrival in case ofan emergency.

• Eating out in the UK is expensive. Askyour Link partners to show you wherethe local supermarkets are.

• Often staff canteens provide subsidisedfood.

• Provide visitors with an initial amountbefore travelling in case of emergency.


GENERAL INFORMATION

• You will need a visa to enter the UK.Apply for this from your nearest BritishHigh Commission/ Embassy. Do thisseveral months in advance of your visitas it can take a long time to process.Your flight will not be booked until yourvisa has been approved. Ask your UKpartners and the Director of your hospitalto write support letters.

• Securing a visitor’s visa to the UK hasbecome increasingly difficut. Make sureyou submit all the required documents.

• Agree with your UK partners who willbook and pay for the tickets. As manyairlines now offer electronic tickets it ispossible for the UK partner to book theflights.

• Try and avoid visits during the mostexpensive peak times.

• Find the cheapest airfares.

• Don’t book the flight until the visa hasbeen secured as if the visitor doesn’t getthis you may have wasted a flight.

Working with children will automaticallyneed a Criminal Records Bureau (CRB)check first which often takes a long time.

You may also require a hepatitis screen andoccupational health check by the receivinghospital.

The cost of Living in the UK will besubstantially higher than in your homecountry. Be clear on who will provide thesubsistence costs and make sure thatvisitors are clear how much they will receivein advance. The subsistence money providedshould cover essentials while in the UK.Make it clear to participants that they willnot be returning home with any additionalmoney. This will be around £80-£150 a weekin addition to accommodation costs.

82

2.5Visits to theUK organisation

2.5

Baggage andwhat to take

Insurance

Communica-tion

Accommoda-tion

In case ofemergency

Professionalregistration

GENERAL INFORMATION

It is best to travel as lightly as possible asthis will give you space to bring anyequipment or books back with you. Mostairlines only give 20 or 25kg baggageallowance plus 7-10kgs carry-on luggage andthey will charge a lot of money if you go overthe allowance. The UK may be much colderthan your country, depending on the time ofyear. Make sure you take appropriateclothing. October to March tend to be thecoldest months and expect it to rain at anytime of year. Get advice from your UKpartners on suitable clothing.

Let people know what airline baggageallowances are for checked in and handluggage.

The NHS will only cover the health careneeds of non-EU patients in medicalemergencies. Repatriation costs will not becovered. It is advisable to take outappropriate travel insurance which will coveryou in case of a medical emergency.

If you have a mobile phone which is not tiedto a particular network, it should be able toaccept a UK SIM card. Pay as You Go simcards are cheap, although calls overseas canbe very expensive. See Chapter 2.3 whichgives details of communication.

Check with your UK partner that they arearranging accommodation for you and whatfacilities you have access to.

Establish who you should contact in case ofan emergency. Have the telephone numbersof at least two contacts with you at all times.

It is unlikely that you will be able to do any‘hands-on’ work whilst in the UK as you needto go through a process of accreditation.Therefore much of your work will be limitedto observation.


• Ask your UK partners if they are able toprovide visitors with some warm clothing(e.g. coats/ jackets, gloves, boots) toavoid purchasing new items.

• Travel light on the way out.

• Do not exceed the airline baggageallowance on your return as excessbaggage is charged at very high rates.

• Weigh your bags before travelling.

• If you have some spare room ask yourUK Link partners if there are any books/equipment that needs to be taken backto your home organisation.

• Find out about relevant travel insurance.

• Ask your UK Link partners where youcan get a UK sim card from.

• Share your number with both UK andcolleagues and family back home.

• Stay in email contact with staff at yourhome organisations to let them knowhow you are getting on.

• Find out the address and telephonenumber of your accommodation beforearriving so that you can find it in case ofemergency.

• The UK emergency services(ambulances/ police/ firemen) can becontacted by dialling 999 on any phone.

• You will probably need to go through anoccupational health check at the UKpartner organisation. Ask them what thisinvolves.

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2.5Visits to theUK organisation

Dos and Don’ts in the UK

Follow-up after visitsBefore the end of your visit to theUK, sit down with the colleaguesyou have been working with andreview your visit. Reflect on someof the things that you have learntand which you may want to dodifferently on return home.Develop a plan of action for yourreturn to your home organisation,do this jointly with your partners.This will give you a joint vision,and give your UK partners anindication of how they can help tosupport you further. Your UKpartners will learn from yourinsight.

The next steps are to:

• Write a visit report focussingon the key things you learntduring your time in the UK,think about how these arerelevant and can be adapted toyour home context. Share thatreport with your UK partners.Relate how your visitcontributes towards theongoing aims and objectivesof the Link.

• Meet with your managers toshare what you learnt. Arethere any changes you think areworth implementing and why.How can these changes bemanaged?

• Run a session for colleaguesto share your learning and getthem involved in any changesyou are planning.

• Set objectives for changewhich can be followed up withyour UK partner on their nextvisit.

• Suggest any further trainingyou think you or yourcolleagues may benefit from.Some of this may involvefurther training in your owncountry or neighbouringcountries rather than furthervisits to the UK.

• Update the Induction pack forfuture colleagues who will betravelling to the UK.

• Keep in regular contact withyour UK partners, ask them foradvice and support when youare implementing changes.


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WHILE IN THE UK DO...

Ask as many questions as you need to and gatheras much information as possible. Remember this isa learning opportunity for you and the moreenthusiastic you are, the more you will get out of it.

Find out what relevant conferences or workshops arehappening and see if you might be able to attend.

Praise the Link and explain why it matters to youand your DC colleagues. You are an importantambassador for the Link.

WHILE IN THE UK DON’T...

Don’t forget your time-keeping – people in the UKtend to be very punctual. If you have a meeting tryto arrive at least 5 minutes early for it. If you arehalf an hour late the meeting may be over and itwon’t reflect well on you.

Don’t travel without letting your UK partners knowwhere you are going and give them the contactdetails.


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}DCCASE STUDY

“I went on a Link visit toEngland to get exposure tocommunity mental healthcare in the UK in order toimprove mental health caredelivery in Mbarara, Uganda.I was able to learn a lot asthe services are welldeveloped with goodresources, adequate staffinglevels and care is providedwithin a standardiseddelivery system. Most thingsare well organised, peopleare serious with time-keeping and very committedto work.

I would advise thoseundertaking a similar visit,to be aware that the workingenvironment and delivery ofservices in the UK is quitedifferent but one should beopen minded, ready to learnand pick what is relevantand apply this to developand improve services athome. While on the surfacethere is a higher standard ofliving and pay in the UK, oneshould endeavour to returnand work to improve thesituation at home.”

Elias Byaruhanga,Psychiatric Clinical officer,Mbarara, Uganda

CHAPTER CHECKLIST

} Decide whether theobjectives of the Link canbe met with visits to theUK.

} Develop specificobjectives for each visitthat can only be met byvisiting the UK.

} Ensure that the bestpeople are involved in thevisits. Ensure each one issigned off personally bythe head of DCorganisation, bearing inmind the risk of addingto the brain drain.

} Develop a visit scheduleand tie this in with anyconferences or othertraining opportunities.

} Use the visit to furtherstrengthen relationsbetween your twoorganisations, review howthe partnership isdeveloping and whetherthe MoU requires review.

} Plan and make travelarrangements well inadvance.

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The strength of Links is in theircontinuity and sustained supportover time. This will involve directtraining visits but of equalimportance is the support,encouragement and mentoringthat takes place between thedirect visits and contact sessions.

In addition, monitoring andevaluating the progress of yourLink is important to determinewhether the agreed objectives arebeing achieved. You should alsoconsider sharing informationabout your work and any lessonslearned. This Chapter gives youideas and guidance about theseissues.

In this Chapter:• Mentoring and

support

• Equipment andbook donations

• Monitoring andevaluation

• Joint Research;disseminating andpublishing yourwork



Mentoring and supportMentoring is an arrangementwhereby one person supportsanother to develop their skills,improve their performance andmaximise their potential.Mentoring is more than just givingadvice. It is also about motivatingand empowering the other partnerto identify their own issues andgoals and helping them find waysto achieve these.

Health worker shortages inDCs often mean that manyprofessionals find themselvesworking in relative isolation.Their UK counterparts tend towork in a much larger teamreceiving support from manycolleagues. Mentoring can helpto provide DC partners with theprofessional support they need.

If you have been involved inworking closely with a colleaguefrom your partner organisationduring an exchange visit, it maybe helpful to continue therelationship through mentoringor seeking other support such asadvice, contacts or referenceswhen needed.

REMEMBER!

If you do not have colleagueswho can support youprofessionally maybesomeone from your Linkpartner could provide remotesupport.

Establish what you maywant from the relationship.Perhaps they might be ableto talk through some difficultcases with you, advice on howto take your work forward, orshare relevant books andarticles with you.

Ask around and find someonewho has the time to help you,establish the best method forcommunication, and call onthem whenever you needtheir help. Even if you /theyhave not been directlyinvolved in exchange visitsor your areas have not beenidentified as key focus areasfor the Link, you may still beable to receive supportthrough mentoring.

See also the TelemedicineLinks on p131.

Equipment and bookdonations

Occasionally, it may beappropriate to send equipment,books or journals from the UKto the DC organisation. Ifplanned correctly, this can beof enormous benefit to the DCpartner and can help alleviatesome of the problemsassociated with working ina resource-poor environment.However, before doing this, itis important to consider thefollowing:

• Has the DC partnerrequested it? Developingcountries are not a dumpingground for old equipment,books or computers.

• Are they relevant to theagreed needs of thepartner? Ancient journals oroutdated text books are likelyto be of little use.

• Is the item suitable for theDC partner’s requirements?Are spare parts andconsumables availablelocally? Is there the technicalback-up that may berequired? Should surgeprotectors be used to protectthe item against fluctuationsin the local electricity grid?

• Does the equipment complywith national guidelines?

• Is it possible to purchasethe item locally, is thischeaper rate than theshipping costs? Remember,purchasing locally alsocontributes to the localeconomy.


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f CASE STUDY

Donated equipment

Action Zambia is a UK registered Charity which supports the work of the Link between LeedsPartnerships NHS Foundation Trust and Chainama Hills College Hospital. Chainama Hospital is theonly mental health hospital in the country serving some 12 million people.

The physical environment and general patient amenities are poor and staff requested assistance toimprove both aspects. The charity is in a working partnership with the hospital management teamand the Link to complement the hospital’s own planned renovation work.

As this work is aimed at the fabric of the buildings, the charity has focused on providing pieces ofequipment which were specifically requested. This included beds and mattresses and IT equipmentto enable the Link to establish a learning lab and video teleconferencing facility.

The charity has also purchased an industrial-sized washing machine for the hospital laundrydepartment which did not have one that worked. The model was selected by the hospital andpurchased and shipped from the UK, as it could be bought much cheaper in the UK than in Africa.

Future plans are to support the development of therapeutic occupational activities (e.g. gardening,carpentry and chicken rearing) which will equip patients to be more independent on discharge andaid social integration.

FIND OUT MORE

Equipment and book donations

• Refer to Appendix 8 for further health information resources. These are targeted at sharingup-to-date information in DC. This includes the HINARI programme, TALC, HIFA2015 knowledgenetwork and many more.

• THET’s guidance sheets on Making Donations and Shipping Donations are available fromwww.thet.org.uk.

• The WHO advocates for four underlying principles of good practice when transferringequipment:

1) Health care equipment donations should benefit the recipient to the maximum extentpossible.

2) Donations should be given with due respect for the wishes and authority of the recipient,and in conformity with government policies and administrative arrangements of therecipient country.

3) There should be no double standard in quality. If the quality of an item is unacceptable inthe donor country, it is also unacceptable as a donation.

4) There should be effective communication between the donor and the recipient, with alldonations made according to a plan formulated by both parties.

• Refer to the WHO Guidelines for Health care Equipment Donations.www.who.int/hac/techguidance/pht/1_equipment%20donationbuletin82WHO.pdf

• Also consult the Appropriate Health Technology Group guidelines available at:www.conferences.theiet.org/aht

UK

Monitoring and evaluation(M&E)Monitoring and evaluating thework of the Link may seem less ofa priority than the actual activitiesyou are undertaking. Many Links,pressed for time and resources,have tended to push it aside. It canalso seem hard to measure changeand attribute the Link as thecausal factor for this change whenthere are so many other variables.

But good monitoring andevaluation is vital if the Link isgoing to make an impact. It willhelp the Link improve its work andshow others it is worth investingin. Getting it right from the startis important: if you stated youroutcomes 'SMART’–ly during theinitial planning process (see p46)it will be easier to evaluate lateron.

THET has developed an excellentM&E Toolkit5 especially aimed athelping Links to monitor andevaluate their work. Links areadvised to consult a copy duringthe early planning stages of a Link,factoring evaluation in right fromthe beginning.

FIND OUT MORE

Monitoring and EvaluationToolkit

What Difference are weMaking? A Toolkit onMonitoring and Evaluation forHealth Links, by Mya Gordonand Caroline Potts.

This Toolkit, designedespecially to help HealthLinks evaluate their work,makes the sometimescomplicated task ofevaluation look easy. It isdivided into six easy-to-followchapters:

1. Monitoring and Evaluationin Context

2. Planning to Monitora Link Project

3. Practical Tools forCollecting Data

4. Tips on Analysing Dataand Writing Reports

5. Designing an Evaluationof a Link

6. Follow-up to Evaluations

The Toolkit was publishedin 2008 and is available fordownload from THET’swebsite or hard copies canbe purchased fromwww.cpibookdelivery.com/our-books/tropical-health-and-education-trustat a cost of £10.50 a copy.

Joint research; disseminatingand publishing your workThe work you are doing is likely tobe relevant to other people. Youshould consider how your workcan be shared with others andwhat the best way of doing this is.

Developing countries tend not tohave the same tradition of doingresearch or writing papers as inthe UK. Many journals have anorthern-centric approach andthere is a bias to anglophonepublications. If something ofinterest is emerging from yourLink, discuss the possibility ofdeveloping joint researchcollaborations. This can bepresented as another dimensionof partnership.

There are two types of papers youmay think about publishing. Thefirst is a descriptive study sharingexperiences from your Link: whatyou did, how you did it and anychanges that resulted because ofit. This will allow others doingsimilar work to learn from yourexperiences and promote HealthLinks.

FIND OUT MORE

Leather et al. Workingtogether to rebuild healthcare in post-conflictSomaliland, The Lancet2006, vol. 368, no9541 pp.1119-1125

Baillie et al. NHS Links:Achievements of a schemebetween one London MentalHealth Trust and UgandaPsychiatric BulletinAccepted 7 July 2008


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5 What Difference are we Making? A Toolkit on Monitoring and Evaluation for Health, by Mya Gordon and Caroline Potts.

/

The second type of paper iscollaborative research. This mayinvolve working together to look atlocally relevant disease patterns,treatment protocols or services.

What type of research isimportant? Research should beencouraged that:

• Improves clinical treatment.

• Stimulates planning e.g. bygenerating statistics and abetter understanding of theburden of disease.

• Measures outcome so thatyou can see the effect of theintervention.

• Develops services throughoperational research.

• Develops people that usesand develops local skillswherever possible.

FIND OUT MORE

Walker et al. Eosinophilicglomerulonephritis inchildren in South WesternUganda Kidney International2007, vol. 71, 569–573.

Alemu S , Prevett MTreatment of Epilepsyin Rural Ethiopia: 2 YearFollow-up, 2004,Ethiop.J.Health Dev.Vol 18(1):31-34

Carter E, Yifru S, ArchdeaconC, Barbrook C, GebremedhinM, Setting Up Clinical Auditin Gondar Hospital, Ethiopia,2008. Ethiop Med J, Vol. 46,No.3

Target your paper at the mostrelevant journals. Each journal’swebsite normally has instructionsfor authors with writing andsubmission guidelines. Manyjournals also have online versionswhich are more substantive thanthe paper versions. Most of thegeneral medical journals are keento draw attention to global healthchallenges/issues and can do so ina variety of guises - not justsubstantive papers. Many of thesehave news sections and siteswhere people can post blogs abouttheir experience and views. This isalso another avenue for drawingattention to your Link.

Remember that THET can alsopromote and share your workthrough our e-bulletins. So if youhave a story to share please emailus on [email protected]

CHAPTER CHECKLIST

} Effective communicationis one of the mostimportant aspects ofLinks.

} Keep accurate recordsof the work of the Linkand share them withpartners.

} Monitoring and Evaluationshould be high up theagenda. Make sure youhave a copy of THET’sM&E Toolkit.

} Where possible, try topublish your work anddevelop joint researchprogrammes.


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Photograph (right): John MacDermot, Somaliland

Without trained andmotivated health workers,the Millenium DevelopmentGoals will never be met.

In this Chapter:• Barriers preventing

change

• Supporting change

• Putting learninginto practice

Some factors may exist whichprevent desired changes fromhappening. Potential barriers tochange need to be identifiedbefore any activities take placeor are planned.

This Chapter helps you to identifysome of the barriers which mayprevent change and how thesecan be overcome.

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2.7Managingchange

Barriers preventing changeOn their own, short trainingsessions rarely result in long-termchanges in practice. The Linkshould be forward-thinking andplan ongoing training, supportand mentoring in order to enablechange.

Barriers to change may need to beaddressed before change happens.It is important to be aware that aLink can demotivate and disillusionpeople if they are not able to putthe knowledge and skills theyacquire into practice.

When establishing the objectivesand undertaking the activities of aLink (as described in Chapter 2.2),it is vital to consider whether theenvironment will enable change totake place. For example, are theopportunities available for peopleto apply what they have learned?Are the people involved in thetraining actually the ones who willimplement, support and overseethe change?

The following factors should beconsidered before carrying outany training activities:

• Are those involved motivatedindividuals who are efficient atgetting things done and able tomotivate and encourage othersto generate change?

• Consider the suitability andrelevance of the desiredchanges (covered under theR (relevance) of SMART inChapter 2.2). Are those whoidentified the need for changealso the ones who will beinvolved in implementingthem? Do those who need toimplement change also seethe relevance?

• Is there an enablingenvironment where the rightequipment and resources areavailable to implement thechanges?

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FACTOR

Motivation ofindividualsand teams tocreate change

Relevance ofthe training

Systems inplace toencouragechange

PREPARATORY STEPS THAT MAY NEEDTO BE TAKEN...

• Identify pro-active people who will be ableto drive forward the desired changes –these won’t always be people at the top.Involve them in the decision-makingprocesses.

• Empower people to be drivers of change.Giving people responsibilities, supportingand encouraging self-belief are excellentways to make ambitious people flourish.Link activities, especially support andtraining visits by DC staff to the UK haveproven to be a means of encouraging this.

• Is it relevant to discuss promotions andformal qualifications through the Link?

• Before planning any training the UKpartners need to be aware of the localcontext. What challenges and constraintsexist?

• Remember that shortages of healthworkers in many DCs mean that they willnot have the same time/patient ratio as inthe UK. Drugs and diagnostic tests may notalways be available. There may be limitedaccess to equipment.

• If you plan to deliver any teaching, ensureit is made relevant with practical examples.

• Factor in all the inputs needed to put thetraining into practice. Who will providethem?

If there are ongoing costs, it should bethe DC who provides them, as it is notsustainable for the UK partners to do so.One-off costs (e.g. equipment) may besupported by the UK partner. If people arenot able to use their newly acquired skillsthey may end up being more frustratedand de-motivated than before.

THINK ABOUT

• Motivation for change must come fromwithin. Who is driving the change? Is it atop-down or bottom-up decision?

• Is there a strong local champion who canimplement change and motivate others tofollow?

• Do the people being trained believe thatchange is necessary? Are they motivatedto do something about it?

• Is there buy-in from staff? Are thereincentives for those who create change,possibilities for promotion, higher salaries,or further training?

• Is the training relevant to the local context?Does it take into account constraints e.g.resource shortages?

• Are participants able to understand andsee the relevance of the training?

• Do they see how this might bring aboutchanges for the better?

Remember that the aim is not to replicatewhat the UK does, but to learn from this andsee how it can be relevant and adapted tothe local context.

• Will the DC partner (or the UK partner)make the necessary arrangements to allowthose being trained to put knowledge intopractice?

For example, if the Link is training nurses ina particular skill (e.g. paediatrics) has thematron agreed that they will not be rotatedto a different ward three months later, fillingtheir places with untrained nurses?

If the tutors of a nurses' training college arebeing trained to deliver more interactive andproblem-based teaching, will they haveaccess to the required resources e.g. afunctional clinical skills room?

The following table considers each of these factors and suggests steps the Link can take to enable the desiredchanges to happen:

Addressing the barriers that prevent change from happening

Supporting changeFollow-up after any Link trainingactivity is important. At the timeof the training everyone may havegood intentions but these areeasily forgotten after returning toa busy work schedule. Ask yourselfwhat the training will allow you todo better than before? Creating anaction plan and a system ofreminders is important to helpenable change.

An action plan may typicallyinvolve four levels:

1. Immediate changes in practice

2. Changes that will beimplemented in the next threemonths

3. Changes you hope to see in thenext year

4. Identifying further trainingwhich may be needed or whoelse may require training

REMEMBER!

Build an understandingacross the Link of whatfactors have encouragedand/or prevented changeand feed this understandinginto your monitoring andevaluation activities. Thiswill help you learn from theseopportunities and enableyou to do better in future.

FIND OUT MORE

Refer to What Difference arewe Making? A Monitoring andEvaluation Toolkit. THET,2008. See p89.

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!

Learning wasput intopractice

Changehappened

UK LINKS PARTICIPANTS

An evaluation at King's College HospitalLondon identified a UK Link participantwho had changed his outpatient servicesfollowing involvement with a TBprogramme in Zimbabwe.

In rural Zimbabwe, TB services are nurseled, with doctors only making the initialdiagnosis. TB services at King's Collegewere, at the time, led by consultants.After working in Zimbabwe, theconsultant set about changing the serviceat King’s College. He provided training fornurses and they were able to prescribetreatment.

This has transformed the outpatientservice and has benefited everyone. Thepatients are happier because they do nothave to wait for clinic appointments justto pick up drugs. The doctors also havemore time to spend with the patients atthe time of diagnosis. The patientoutcomes are the same and the Trustsaves money.

Favourable factors:

• The person involved had decision-making power. He was able toimplement changes in practice basedon learning from the DC partner.

• Exposure to work in the DC partner wasdirectly relevant to practice in the homeorganisation.

DC LINKS PARTICIPANTS

The Link between Butabika Hospital,Uganda, and East London FoundationTrust has enabled three new services toopen with specialised staff, including adrug and alcohol treatment unit, posttraumatic stress ward and a children'sday unit. The new wards had beenplanned and built before the Link becameinvolved, but there were no specialisedstaff to manage or run them. The Linkprovided placements in the UK (of threeand six months duration) for four stafffrom Butabika Hospital. There wassupport and training from the UK staff inUganda both before and after the longplacement. At the children’s ward trainingwas only provided in Uganda followed bysupport and mentoring.

Favourable factors:

• The new services were planned and theinfrastructure was in place, yet staff stillneeded to develop specialist skills towork in these wards.

• Those who were selected for trainingwere motivated and the training furtherencouraged them to work hard to seeresults.

• The staff have remained on these wardsto use their new skills.

CASE STUDIES

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Learning wasnot put intopractice

Change didnot happen

UK LINKS PARTICIPANTS

Participant B from the UK was involved inhelping to provide mental health trainingto Link partners in Sudan. As it was herfirst time working abroad, she wasfascinated by people’s perspectives andways of thinking about mental healthissues. As her understanding of thecultural values and society increased,she became increasingly aware of thisinfluence. She felt that she was learninga lot more than she was able tocontribute. However, she felt concernedabout some of the language and attitudesof others she travelled with, but she didnot participate in exploring those issues.

On her return to the UK she didn’t feelthat she could draw on any of thislearning. Her patients were mostly whiteBritish nationals. Had her work been witha more ethnically diverse communityfrom similar backgrounds to those of theLink partner, she would have been ableto draw more heavily on this learning andunderstand her clients' needs better.Exposure did, however, allow her reflecton care given. When she later moved toan ethnically diverse area she was ableto draw on her learning more directly.

Limiting factors:

• Learning was not relevant to localcontext, although it did provide theparticipant with a better understandingof cross-cultural issues.

• Language and attitude of others if notdiscussed openly can have a negativeeffect.

DC LINKS PARTICIPANTS

Link A, had the remit of providing on-the-job training to improve the surgical skillsof medical officers. An inter-professionalteam from the UK travelled to their Linkpartner once a year for three years toprovide on-the-job training whilesupporting service delivery.

However, because of high staff turnoverrates, on each visit they encountered newmedical officers and there were no visibleimprovements in the quality of care.

The Link then decided to train some ofthe medical officers (those who lookedlike they would stay in post) to becometrainers, so that they could update theskills of new medical officers.

Four medical officers were selected andgiven advanced training to be trainersover a one week period. There wassubsequently no evidence that thosetrained to be trainers actually undertookthis role.

Limiting factors:

• No systems or support structures toencourage this.

• No incentives to become trainers orteach others.

• Did not tie in with national plans.

CASE STUDIES

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CHAPTER CHECKLIST

} Ensure the Link isproviding long termsupport to enable change,and not just one-off visits.

} Think about the factorsthat can enable thechange. How can youmaximise these?

} Think about all the factorsthat may prevent changefrom happening. How canyou mitigate these?

} Involve those who arecommitted and have theability to make changehappen. Find champions.

} Make sure the training isrelevant and appropriatefor the context.

} Identify additionalresources that are neededto enable learning to beput into practice.

} Agree long-term supportthat may be required(perhaps with an actionplan and plannedreminders).

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}

Photograph (right): Lihee Avidan, Malawi

The potential is vast. It issensible for Links to startsmall – but to aim high.

2.8 Scaling up thework of the Link

100

If Links are committed to makinga significant difference, thenscaling up their work should be theambition of all Links. However, notall Links will reach this stage andsome won't want to.

Careful planning is needed toenable a Link to scale upeffectively, ensure it deliversconsistently and enable it torespond to a new range ofchallenges that emerge as thework grows. This Chapter helpsyou think through the issuesinvolved when scaling up the work.

In this Chapter:• What is meant by

‘scaling up’?

• Why scale up?

• When is the righttime?

• How can it bedone?

What is meant by ‘scaling up’?As the Link develops, you may findthat there are issues that can onlybe addressed if the scale of thework is increased.

Scaling up refers to increasing thescope and funding of the Link in aplanned and strategic way.

In some cases you may be able tofund the increasing costs of thework through local fundraising, butit may also be appropriate to applyto grant-giving organisations.

Why scale up?There are many reasons to scaleup the work of a Link when it isappropriate. Scaling up oftenprovides:

• An opportunity to make abigger impact

• A reason to think rigorouslyabout the work and planstrategically

• Access to larger and morediverse funding sources

• Greater potential to respondto the needs of the DCorganisation and thepopulation they serve

• The possibility of triallinginnovative pilot projects that,if successful, may later bescaled-up to or influence anational programme

• Work that can strengthen andcomplement the Link, extendingits achievements

• An avenue for the Link tobecome further establishedand gain credibility

• A need for rigorous monitoringand evaluation, as demandedby donors


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GDID YOU KNOW?

Health system strengthening

The ultimate goal of all Links should be to contribute to healthsystems strengthening. WHO defines a health system as ‘allorganisations, people and actions whose primary intent is topromote, restore or maintain health.’

According to WHO, the six building blocks of a health systemare:• Good health services with minimum waste of resources;

• A well-performing health workforce;

• A well-functioning health information system that ensuresthe production, analysis, dissemination and use of reliableand timely information;

• Equitable access to essential medical products, vaccinesand technologies of assured quality, safety, efficacy andcost-effectiveness;

• A good health financing system that raises adequate fundsfor health, in ways that ensure people can use neededservices and are protected from financial catastrophe;

• Strong leadership and governance ensuring strategic policyframeworks exist and are combined with effective oversight,coalition building, regulation, attention to system-design andaccountability.

The WHO points out, "while the building blocks provide a usefulway of clarifying essential functions, the challenges facingcountries rarely manifest themselves in this way. Rather, theyrequire a more integrated response that recognizes the inter-dependence of each part of the health system."

FIND OUT MORE

To read more about Health systems strengthening refer to:

• WHO, 2007, ‘Everybody’s Business, Strengthening HealthSystems to Improve Health Outcomes: WHO’s Frameworkfor Action’

• www.eldis.org – Health systems section

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When is the right time?Scaling up the work of the Linkis often best done when:

• There is a clear need and ademand from the DC partnerto scale up the work

• Good relationships have beendeveloped between the Linkpartners

• Each partner has a goodunderstanding of what theother can and cannot do

• You have implemented worktogether and have a successfultrack record

• You have regularcommunication (within andbetween each Link partner)and good systems in place

Most Links only find themselvesin this position a few years afterbecoming established. It is worthintroducing good systems into thework of the Link (as detailed inChapter 2.3) right from itsinception, making it easier infuture to demonstrate what youhave achieved.

How can it be done?Scaling up requires carefulthought and planning. Here area few key areas that you shouldconsider, with questions youshould discuss together:

• Plan together. Whether you areconsidering expanding existingwork or developing new work,there is need for joint planning.As part of the process ofassessing needs and planninga response, it is important toconsider the capacity of bothLink partners.

• Develop plans with clearoutcomes. A detailed plan,based on clearly identifiedneeds, should be developedwith specific aims, objectivesand activities of the project(as described in Chapter 2.2).Make sure your objectives andindicators are SMART. Manyprojects fail because theyaddress only one part of aproblem (e.g. providing atraining course) rather thanaddressing the problem as awhole (e.g. providing a trainingcourse, establishing supportmechanisms, looking at careerpaths, and ensuring people havethe equipment they need toutilise the skills). Make sure thatthe project work is sustainableand relevant. A log frameapproach to planning may helpto clarify your ideas. See p104.

• Make sure there is capacity tomanage the work and that theright systems are in place.Does the DC partnerorganisation have the capacity(communication, reporting,financial) to manage andimplement the work? Does theUK partner have the capacity tosupport more work? Should anyother relevant individuals/organisations be involved toensure a good outcome? Isthere the capacity to embed theproject within the organisationafter the end of the fundingperiod? What is the exitstrategy? Does the Link havethe organisational capacity andcommitment to deliver a biggerprogramme. If not, can capacitybe developed and should this bepart of the programme plans?

• Ensure work is relevant andaligned to country/districtplans. Is the work a priority?How does this project fit withinthe bigger picture? Do you needto involve other local playerssuch as the Ministry of Health?

• Consider working with others:Find out what organisations aredoing so that you avoidduplicating effort and wastingresources. See if any synergiesexist between your areas ofwork and whether, as a groupof Links, you are able to providespecific areas of strategicsupport. You could also thinkabout working in a consortiumwith other Links or NGOs withinthe DC region or country. Youmay also find it useful to speakto THET about your ideas, theremay be potential forcollaboration or support.

• Finding resources. Where willyou get the resources (e.g.people, time and money) todeliver the programme? Willthe UK partner release morestaff to support the Link? Dothey have all the required skillsor do you need to involveothers? Where will you getresources? Can the developingcountry partner devote anyresources to the programme?Will efficiency savings coversome of the costs? Can theUK partner raise more fundslocally? Is there an externaldonor that will support thework. For more informationabout fundraising and funding,see Chapter 2.9.

CASE STUDY

Developing NewServices with theDC organisations

Improving access tohealth services inrural areas throughtraining

EXAMPLE: Developing blood bank & laboratory services, Boroma/Hargeisa

Hargeisa Group Hospital in Somaliland expressed their concerns about the standardsof their laboratory services to their Link partners, King’s College Hospital. Without themeans to store blood, donors needed to be found as and when transfusions wereneeded. Time critical operations requiring blood transfusions could therefore be fatal.

A one year project to address this problem was developed. The full costs of £36,500were supported. Over the course of one year the following activities were carried out:

• Five laboratory technicians from Borama Hospital received basicmicrobiology/cytology training. The training took place over five weeks, the initialtwo weeks were delivered by an experienced haematology laboratory technicianfrom KCH and the rest of the training was carried out at another hospital locally(£3,750).

• The existing laboratory building was renovated and extended (£8,800).

• Basic laboratory equipment was procured and the blood bank was established(£22,000).

• External training support in pathology was given to medical undergraduates atHargeisa and Amoud (Boroma) Universities (£1,950).

Outcomes of the work: A well-managed and effective blood bank has beenestablished enabling timely blood transfusions.

EXAMPLE: Training the trainers to improve trauma outcomes in rural areas ofMalawi

Road traffic accidents (RTAs) are a major cause of morbidity and mortality in Malawi.In rural areas, the ability to respond to these emergencies is often inadequate, withfew trained health workers, yet RTAs are increasing every year. Kamuzu CentralHospital (in Lilongwe, Malawi) asked their Link partners in Middlesbrough to focus ontrauma team training.

The Link trained staff using the International Trauma Life Support (ITLS) course. Inaddition they trained some staff to become ITLS trainers themselves. There was aneed to train health workers from the district hospitals in ITLS, and local trainerswere now available, yet there was no funding available.

A one year project of £8,250 was funded to enable the local trainers from the centralhospital to train health workers from the district hospital. Project activities included:

• Eight three-day training courses were carried out in each of the district hospitals inthe central region of Malawi. Over 200 health workers received training (£4,800).

• Provision of equipment (neck collars, spine boards) and ITLS handbooks to each ofthe district hospitals (£1,200).

• Provision of books to the A&E Department of Kamuzu Central Hospital (£800).

• Coordination, monitoring and evaluation of outcomes (£1,450).

Outcomes: Health workers throughout the district are now better able to treatemergencies. Some empirical and anecdotal evidence of this exists. Bettercommunication occurs between the district hospitals (which have the ambulances)and the Central Hospital (which receives the patients in the A&E department).

Examples where Links scaled up their work

f

2.8

103


FIND OUT MORE

Log frames

A Logical Framework(log frame) is a tool thatis commonly used in thedevelopment sector tocapture information aboutthe aims, objectives,activities, inputs andpotential risks of projectimplementation.

Some donors may requireyou to submit a log framewith an application. But evenif it is not a requirement itcan be a useful tool to usewhen planning a project.It helps you think throughand address the issuessystematically and isdesigned to be used in aconsultative way. Headingswhich may be included arebroken down into the goal,objectives and activities ofyour work with inputsrequired and possible risksand assumptions made. If youstart planning a project witha log frame it can thenprovide a useful basis fromwhich to write the narrativepart of the application.

CHAPTER CHECKLIST

} Identify areas where theLink is able to deliverlarger scale support.

} Assess whether the Linkhas the capacity to delivera larger programme ofwork.

} Find out what others aredoing – build on synergiesand avoid duplication.

} Plan the projectthoroughly.

} Use logical frameworkanalysis to bring yourplans together.


104

}/


A little money given to a Linkcan go a long way.

2.9 Funding a Link

106

This Chapter is primarilydirected at the UK Link partnerwho usually takes a lead onraising funds for the Link,although fundraising optionsfor the DC partner are alsomentioned.

The good news is that there isever increasing local, nationaland international interest in theconcept of Links.As such, morepotential funding sources arebecoming available.

However, there is no magicsolution to securing fundingfor your Link. Raising fundswill absorb a significant amountof time, so it’s important tounderstand which fundraisingactivities are going to be mostcost- and time-effective for yourLink.

In this Chapter:• Developing a

fundraisingstrategy

• Howmuch moneydo we need?

• Who willcoordinatefundraisingand how?

• What are thefunding sourcesavailable?



Developing a fundraisingstrategyLinks rely on their Trust toprovide many of the resourcesneeded to run a Link. This mightinclude coordination time,meeting space and paid leavefor Link training visits. But youwill need to fundraise beyondwhat is provided for by yourTrust in order to support otherLink activities.

Having a strategy in which youconsider your fundraising targets,sources and resources, will addclarity and structure to thesometimes difficult task of raisingfunds to run your Link.

Once you have an understandingof the objectives of the Link, askyourselves four questions:

1. How much money do we need?

2. Who will coordinate fundraisingand how?

3. What are the sources of fundingwe can tap into?

4. What fundraising resourceshave we already got and whatadditional things do we need?

2.9 Funding a Link

107

2.9

REMEMBER!

Benefactor versus collaborating partners

In many cases it is the UK Link partner who takes a leadon raising funds. This is often the case because they areperceived to be the ones with access to the majority offunding sources such as individual donors, grant makingbodies and bursaries.

You need to be careful that fundraising does not createa power imbalance in your Link, promoting a benefactor-beneficiaries relationship instead of being a collaborativepartnership. This is easily avoided if you:

• Jointly plan activities which the Link will undertake(on an ongoing basis) through discussion and dialogue.

• Are open about what funding sources are available andwork together to secure these and plan how they will bespent together.

• Agree which costs the UK and the DC partner can eachabsorb. For example, the DC partner may be able to includesome Links activities in their yearly budgets, making somefunds available for planned workshops, training of staff,and necessary equipment. Not all these resources arefinancial.

• Explore the funding sources available to the DC partner.This may include local/international grant-making bodies,embassies and high commissions and local businesses.

• Remember that money, while necessary to oil the wheels,is not the most important currency of a Link. The mostimportant currency is partnership between healthworkers, with both sides giving and learning.

UK

How much money do we need?When developing the Link plans(as described in Chapter 2.2) it isimportant to be realistic about thefunding that might be available toyou. There is no point in makingambitious plans if no thought isgiven to where the funding willcome from. If you do, the Link risksmaking empty promises which itwill not be able to deliver.

But without clear plans you mayhave difficulty convincing peoplethat your work is worthsupporting. When thinking abouthow much money you need, it is agood idea to:

• Prioritise – Break the objectivesdown into costed activities to beaddressed in order of priority.This will provide a fundraisingtarget and allow activities to becarried out as the funds areraised.

• Plan your income – This is thekey to sustainable funding. Thefurther in advance you can planthe better.

• Allow for contingency –Because plans andcircumstances change. Oftenthe programme work agreed byLink partners evolves throughthe year and unanticipatedcosts can emerge. Ensure yourfundraising plans take accountof this.

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G DID YOU KNOW?

Tips when costing activities

• Jointly develop budgets and agree on costs.Break activities down into their component parts andcost these individually.

• In some places there is a legacy of per-diems paymentsfor attending external workshops. If participants have hadto travel long distances it is important that either theirorganisation or the workshop organisers cover costs.If participants do not incur additional costs, per diemsshould be discouraged as this ensures that only the mostcommitted people attend.

• Remember that donors support the Link to help deliverthe outcomes and activities you promise. As such, the Linkdoes not own the funds itself, but is a custodian ofmoney, and is accountable to both donors andbeneficiaries. First class travel, expensive accommodationand other lavish activities cannot be justified. Equally,badly planned work wastes money and has no impact.

• Allow for exchange rate fluctuations: It is standard toinclude a 3% inflation rise year on year. You also need tobudget for the cost of transferring funds. See p55 forcompliancy issues.

• If you are developing a budget for grant makingorganisations, remember to recover your managementcosts if they allow these. This is usually around 10% ofthe budget total.

Who will coordinatefundraising and how?Fundraising activities such asresearching donors, writingapplications and organising eventscan absorb a lot of time. It isimportant that you identify howfundraising tasks are going to bedivided between differentindividuals, who is going to haveresponsibility for what and,critically, how much effort theycan be expected to devote to it.You might want to consider:

A fundraising committeeTry to get as many peopleas possible involved in afundraising committee.The types of people youwant to include on a fundraisingcommittee may not be the sametype of people as those on theLink Committee.

They need to be able to havetime to organise events or writegrants and the more wealthycontacts they have the better!

People to include on afundraising committee mightinclude retired doctors orteachers, local businesspeople such as bankmanagers or someone from thecommunications departmentwithin your organisation.

A dedicated fundraiserSome Links have taken ona paid (usually part-time)fundraiser or an administratorwho can carry out fundraisingtasks. This is an option but onlyif you can be confident they willbring in funds far higher thanthe cost of their salary.

2.9 Funding a Link

109

2.9

SAMPLE BUDGET

£ number Total (£)

Visitors to the UK (4 per annum)Visas/passports 100 4 400Flights 800 4 3200Travel to/from airport 40 4 160Accommodation and living for 3 weeks 800 4 3200Misc expenses 100 1 100Subtotal: 7,060

Visits to the DC (6 per annum)Visas/passports 70 8 560Flights 550 6 3300Travel to/from airport 50 6 300Insurance 40 6 240Accommodation and living for 2 weeks 300 6 1800Antimalarials/immunisation 100 6 600Subtotal: 6,800

Books and equipment costsJournal subscription 150 1 150Books and support training 300 1 300Shipping container ofhospital-procured equipment 1500 1 1500Subtotal: 1,950

Link management costsCosts for fundraising activities 200 2 400Evaluation costs 2000 1 2000Conference and trainingattendence costs 300 1 300Subtotal: 2,700

TOTAL COSTS year 1: 18,510

SAMPLE FUNDRAISING PLAN

Unrestricted income:Payroll giving 6000Events 4500Contribution from Trust Board 4000

Restricted income (for specified activities):Grant-making trusts 5500

TOTAL: 20,000

What are the funding sourcesavailable?

As a general rule, a Link shouldaim to have a diversity ofincome sources. When it comesto planning your fundraisingstrategy, a good place to start isa 'donor mapping' exercise (seeAppendix 9 for an example).

Think of all the potentialsources of funding available toyou. You may want to rank themin terms of efficiency, timeneeded to be invested,probability of success and scale/amount of funding. Howeversome forms of fundraising arealso good advertising for theLink and your work, so you maynot always want to be too rigidin assessing the financial gain.The following table highlightssome of the main sources offunding available to the UKteam.

There may also be somesources of funding for the DCorganisation which are worthexploring. Perhaps a localbusiness might be willing tofund some of your work. Arethere any local NGOs or grantmaking bodies who you couldapply to for funding? Somegrant-making organisationsprefer to provide funds directlyto the country they aretargetting. And remember, themore Links activities you areable to include in yourorganisation’s mainstream plansand budgets the more the Linkscan achieve.

EXAMPLE

Duties for a fundraiser or fundraising team

• Working with the Link team to agree a fundraising targetaccording to the planned objectives and activities.

• Developing a 3-year fundraising strategy.

• Developing a schedule of potential grant deadlines andliaising with the Link team (UK and overseas) to submitfunding applications. Provide feedback for reasons onfailed applications.

• Deciding whether payroll giving is viable. If so, liaising withthe payroll department to see if they are supportive(ideally an opt-out scheme for new staff), producing formsfor people to sign up and promoting the scheme.

• Liaising with the Communications team to support thedissemination of good news about what the Link isachieving (through press releases, articles for localnewspapers, magazines, leaflets, posters etc.). This mightencourage unknown donors to come forward.

• Organising or enabling others to organise ad-hocfundraising events.

• Networking with other Link fundraisers to share goodpractice and expertise.

• Keeping the project lead and the Link partners regularlyupdated about fundraising activities.

• Being aware of the organisation’s policies on fundraisingand keep within them.

• Taking forward charity registration if it is deemed theright route.

• Liaising with local groups e.g. rotary, church, diaspora,to raise funds from the community.

• Coordinating financial donations such as relevant booksor equipment.

• Liaising with THET and other relevant organisations todiscuss any potential workstreams that need funding, tosee if other Links are doing similar work and whether THETmay be able to support and advise a consortium bid tolarge donors such as Comic Relief or the Big Lottery Fund.

2.9 Funding a Link

110

UK

2.9 Funding a Link

111

SOURCES OFFUNDS

Individualevents

Your Trust /organisation

FIND OUT MORE

• Type ‘A to Z of fundraisingideas’ into an internet searchengine to get a broad rangeof ideas.

• Institute of Fundraisingwww.institute-offundraising.org.uk

• Charities Aid Foundationwww.cafonline.org

• Charity Commissionwww.charitycommission.gov.uk

If you are registered as a charity(see p55), or working throughone, all donations fromindividuals (provided they aretax payers) can be Gift-Aided,allowing you to claim the taxback.

See p38 for information abouthow to make a case to yourBoard.

DID YOU KNOW?

One-off fundraising activities can take a lot of timeto organise for a relatively small return. This canwork well if there are enough people to share theworkload.

Try getting medical/nursing students involved whocan organise events through RAG weeks. You mayalso think about events such as sponsored walksor Valentine's balls. Remember that fundraisingactivities of this kind are a great opportunity topublicise the work of the Link and give it a muchhigher profile.

You can get staff at your organisation to supportthe Link through 'Payroll Giving', where staff makea regular monthly donation which is taken straightfrom their payroll. Setting up the scheme and gettinga critical mass of people signed up can be time-intensive at the beginning, but once established,it can provide a regular income for the Link withrelatively little effort. The first step is to check thatyour Trust supports payroll giving.

Communicating the work of the Link to colleaguesis important to get them interested and support you.Think about setting up a website for the Link,a newsletter or having a notice board.

If you are able to demonstrate that the Link providesstaff with training and development opportunitiesand brings benefits to the organisation and itspatients, the management may be willing to supportthe Link more actively.

2.9

G /


2.9 Funding a Link

112

SOURCES OFFUNDS

Grant givingorganisations

FIND OUT MORE

Internet sources which listgrant-making organisations:

• www.funderfinder.org.uk

• www.guidestar.org

• www.trustfunding.org.uk(annual subscription fee)

Some important sources of fundsfor Links are:

• Health Links Funding Schemedue to start in 2009 (£1.25million a year for three years).Funded by DFID and DoH inresponse to the Crisp Report.

• Development Partnerships inHigher Education (DELPHE): aDFID scheme which supportshigher education partnerships– up to £50,000 a year for upto 7 years.

• The Welsh AssemblyGovernment funds Linkswhere the UK partner is basedin Wales. In 2008 a total of£50,000 was awarded.

• The Scottish Governmentsupport Links, particularlywith Malawi and Zambia.

• The Commonwealth FellowshipScheme funds professionalsfrom commonwealth countriesto come for up to 3 months todo a placement in the UK.

• The BMA Humanitarian fund

• Royal Colleges, Rotary, Masons,etc.

DID YOU KNOW?

Find the right donors to fund your work. There aremany different donors, each with their preferredareas of engagement and geographical focus. Do notwaste time applying for grants if your work does notmatch their criteria. If you are thinking of applyingto larger donors, such as Comic Relief or the BigLottery Fund, think about applying in a consortiumwith other Links if you are doing similar work.

Some grant-giving organisations have their ownformat for application. If not, the fundraisingapplication should contain:

1. The need – what is the problem? How serious isit? Why is it worth addressing? Who are thebeneficiaries?

2. The response – what is the Link proposing to doto address the problem? Why is this a goodapproach? Why is the Link the best one to do it?Focus on the outcomes the work will deliver.

3. The bigger picture – how does the work fit in tothe bigger picture? Who else is working in thefield? What is being done to avoid duplication?

4. The long-term – what will be the long-term impactof this project? What will happen after the fundingcomes to an end? Think about sustainability andexit strategies.

5.Measuring impact – how will you monitor andevaluate your work?

6.A detailed budget

Some donors also require you to submit a logframe.These can be useful planning tools. Refer to p104.

If you receive funding from a grant making body,you then need to ensure that:

• The project delivers what it said it would do.

• There is tight project management so that it iscompleted on time.

• Any changes to plans or spending are agreed inadvance with the donor.

• Reports required by the donor are submitted ontime.

• You monitor, evaluate and disseminate learningfrom your Link.

G /

2.9 Funding a Link

113

CASE STUDY

Alan Jones, from Health Link Malawi, shares howthey made 'payroll giving' a success:

Original set up:• We got the approval and 'buy-in' of the Trust Board.

• The Trust's Communications Department organisedpublicity information on payslips, the internet, posters andlocal newspaper articles.

• We discussed the pros and cons of donations by payrolldeduction versus Give As You Earn, but opted for theformer as there are more costs involved in GAYE and wewanted to avoid these.

• The payroll system was set up to accept deductions and thefinance team organised to pay over the deductions to theLink. The system was also set up to record donations,gift aid declarations and make gift aid claims.

Encouraging people to sign-up:• We got organisation wide buy-in, starting with Trust Board.

• A few Link Committee members were committed to makingit work and took a lead.

• We publicised the positive things the Link had done.

• We had tangible plans (buying a Landrover ambulance tostart with).

• Our staff were directly involved in the work andparticipated in placements in Malawi.

• We held feedback sessions on previous placements toencourage interest.

• We made it as simple as possible to arrange and administer.

Managing the scheme:• The Trust Finance department administers the scheme:

maintaining records, paying money over to the charity,claiming Gift Aid, keeping simple accounting records

• We do pay a notional monthly administration fee payable tothe Trust to contribute towards time spent onadministration

• Some staff contribute their own time for meetings atlunchtime or in the evenings.

• The scheme does need reinvigorating from time to time toencourage new people to sign up and replace those whomove on. But we are currently looking to expand thisscheme to other local NHS bodies.

We generate around £600 per month (excluding Gift Aidreclaims).

}

2.9

UKCHAPTER CHECKLIST

} Try to develop a realisticincome and expenditureforecast.

} Be realistic about whatresources your Link isable to access beforeplanning activities.

} Set up a fundraisinggroup within the UK LinkCommittee to increasecapacity.

} Explore a variety ofdifferent funding sources.

} DC Link partners shouldexplore local fundingsources that the Link maybe eligible to apply for.

2.10 Ending a Link

114

The enthusiasm with which aLink starts may not lastthroughout its lifetime. Changesin circumstances or a long periodof inactivity may lead one or bothpartners to consider ending theLink.

This Chapter looks at some of thereasons why a Link may becomedefunct and how these situationscould be avoided. Perhaps theLink was established with setobjectives or timeframes in mindwhich are then achieved. If youdo decide that it is right to endyour Link, this Chapter suggestssome good practice for how thiscan be done.

In this Chapter:• Six reasons for Link

inactivity (and howthese can beavoided)

• Ending a Link (butmaintaining a goodrelationship)

Six reasons for Link inactivity(and how these can beavoided)It is easy to be enthusiastic at thestart of a Link. As the DC partner,this might signify opportunities forstaff development, changes atyour place of work and benefits topatients. As a UK partner you mayfeel that this is your opportunity tomake a difference and be involvedin exciting work with colleaguesoverseas.

Sometimes this enthusiasm doesnot last. This does not necessarilymean that you should end theLink – in fact some of the longestrunning Links have had longperiods of inactivity or lapses incommunication. Do not becomedespondent too soon. However,it is useful to identify some of thereasons which may lead one orboth partners to think aboutending the Link and look at howthese situations can be avoidedin the first place:

1. Change of keypersonnel whodrove the Link.

6. End of FundingPerhaps the Link

had project fundingwhich has nowcome to an end.

2. Originalobjectves have

been met and thereis no futurejoint vision.

Reasons thatmay causelong periodsof inactivityin a Link

3. CompetingInterests

Partners not ableto dedicate

time to the Link.

5. Priorities nolonger relevant

The priorities identifiedin the original jointplanning are no

longer relevant andit’s time to reassess

objectives.4. Loss ofenthusiasmMaybe results

aren’t being felt byeither partner?

2.10 Ending a Link

115

2.10

REMEMBER!

A lack of communication between partners is the main factor that can strain the Link relationship.Each partner's perceptions of the cause of the silence may be different. The DC partner may bewaiting for a response on an issue from the UK partner, who may in turn be waiting for acommunication from the DC partner.

While the distance between you may be large, it is very easy to get in contact if you establishthe best methods of communication (see section on communication in p52). If you allowcommunication to stop, the Link will be in peril. It is best to make a phone call if there has beena lack of communication.

!

REASON FORCHANGE INCIRCUMSTANCES

Change in keypersonnel

Achieved originalobjectives orpriorities

Competing interests

Loss of enthusiasm

Priorities no longerrelevant

End of funding

HOW COULD THIS HAVE BEEN AVOIDED?

Ensure that several people are involved in the Link at both ends and people withspecific responsibilities work in teams rather than individually. The loss of a veryactive and motivated person will be felt, but this will be reduced if their work caneasily be taken up by someone else.

The more established the Link is, the more it is embedded in the work of theorganisation and the less likely a change of personnel will affect it. Formalagreement of a Trust Board or Governors will help ensure a Link continues to besupported when key senior managers move on.

Changes at a management level from someone who has been very supportive ofthe Link to someone who is not, will have a greater impact.

If the Link was set up to achieve specific outcomes which have now been achieved,and little follow-up planning has taken place, the Link may find itself without a clearvision.

It is time to carry out a review and see what has gone well and start planning afreshfor the future. Alternatively, perhaps the Link has done its work and is no longerneeded. If so, end it well with a celebration of achievements for both parties.

Maybe your organisation has another Link which is achieving more, or takes upmore time. Perhaps management has decided that other priorities mean the Linkcannot continue. When engaging in a Link ensure that it has a purpose andobjectives of its own so that its outcomes will be equally important.

Not meeting expectations or not being able to see the impact the Link is having arethe most common ways for one or both parties to lose interest in the Link. Makesure objectives are SMART (see Chapter 2.2) and do not be too over-ambitious atthe start of the Link. Manage the expectations of your partners (this applies both toUK and DC partners) and remember that it is always better to under-promise andover-deliver than to overpromise and lose enthusiasm.

Perhaps the priorities identified during the initial planning are no longer relevantor there has been a change in the national health policy. This may require anotherjoint planning session to update plans and priorities.

If the Link has project funding, make plans for when this will end so that the end ofthis funding does not mean the end of the Link. Continue with fundraising activitieseven while the Link is financially secure.

116

2.10 Ending a Link

117

2.10 Ending a Link

Ending a Link (but maintaininga good relationship)

If a Link has been inactive for along period of time, and no jointvision or action has emerged eventhrough communication, there aretwo choices: to resolve it or to endit.

If one or both partners decide theywant to end the relationship, whatis the most responsible way ofdoing it?

• Communicate with yourpartners and discuss thereasons for wanting to endthe Link.

• Reflect on the achievementsof the Link and any other aimsthat partners had hoped toachieve but have not done so.

• If the DC partner still has needsthat can be addressed by a Link,but not by the current partner,these should be discussed.The UK partner may be ableto broker a new Link with arelevant UK organisation,and share documents andexperience to ensure asmoother transition. Considerwhether the UK partner alsowants to make a new Link.

• Inform any third parties whohave been involved so they areaware that the Link has cometo an end.

• If you had a Memorandumof Understanding, make anaddendum to it which highlightsthe termination of yourrelationship.

REMEMBER!

An inactive Link does notnecessarily mean that itneeds to be ended. Some ofthe longest running or mostsuccessful Links have hadperiods of inactivity. A Linkshould be able to respond tothe needs of the DC partner,and if no joint vision exists atthat time, the Link may liedormant until the needarises. As long as thecommunication channelsremain open betweenpartners, this is not aproblem.

CHAPTER CHECHLIST

} Consider some of therisks your Link may faceand take measures toavoid them.

} Periods of inactivity donot mean that the Linkneeds to be ended, butmake sure that thecommunication channelsremain open.

} Communication is thekey to good Linkrelationships. Ensurethat there are nocommunicationbottlenecks holdingup your work.

} End a Link responsibly:discuss future needs withpartners and informrelevant parties.

} The UK partner shoulddiscuss the needs of theDC partner and helpthem to broker a newLink with anotherorganisation ifappropriate.

2.10

! }

2.11 Limiting andavoiding risk

118

Setting up and implementinga Link programme exposesindividuals and organisations torisk. Risk is part of everyday lifebut it is important to understand,assess and mitigate against theserisks.

This Chapter provides a briefintroduction to the subject of riskand due diligence. It suggestsissues and documentation whichneed to be considered. It isadvisable to involve those withinyour organisation who haveexpertise in this area to carry outthe Link risk assessment.

In this Chapter:• Why do Links need

to do a riskassessment?

• How to do a riskassessment?

• Risk managementdocuments

• Insurance as a wayto mitigate risk

• Professionalliability, indemnityand registration



Why do Links need to doa risk assessment?As a Link is an organisationalpartnership, it is vital that duediligence and duty of care aredemonstrated during theplanning and implementationof the Link. Identifying risksand briefing participants inappropriate emergencyprocedures will ensure thatvulnerability to these risks isreduced.

Organisational and individualrisks need to be identified,assessed, and mitigated against.It is the responsibility of boththe management and the LinkCommittee to ensure that safeworking practices are agreedand adhered to during visitsto the overseas partnerorganisation. It must be clearin advance what theorganisation is responsibleand liable for, and what theindividual Link participant isresponsible and liable for.

While issues of risk and duediligence will apply to both theUK and the DC partners, somerisks will be greater in the DCand will be of greater concernto managers in the UKorganisation. If concerns existaround the potential risks, itcan be helpful to have someonefrom a successful Link,particularly at the UK end, totalk with the Board to discusshow benefits of the project canoutweigh risk.

REMEMBER!

Follow the “If it has not beenwritten down, it has not beensaid “rule”. Ensure you createclear risk management andduty of care documents.

All people involved in visitsshould be fully briefed andaware of safe workingpractices, with the importantinformation recorded asbeing read and understood bythose involved in the Link.

How to do a risk assessment?Managing risk need not be adaunting or cumbersome process.All NHS organisations and someuniversities have governancedepartments and risk assessmentpolicies. Working with theseexisting structures will helpstrengthen the assessmentbecause you involve individualsthat have expertise in this area.It will also serve to developownership for the Link by involvingthe organisation in the riskassessment and extendingopportunities for engagement inthe Link to those working in theseareas. The rest of this Chapterprovides a brief introduction tosome of the things you may wishto consider.


119

2.11

!

Risk assessment and analysishelps you identify the most likelythreats you will face, and how toavoid them. These can also includethreats to do with liability andlitigation as well as threats relatedto security and safety. Goodknowledge of the operatingenvironment will give you thecontextual knowledge you need tocomplete a risk assessment. Riskassessments can be carried out infive simple steps:

1. List existing threats, both interms of organisational threatsand those that could affectstaff while overseas. Knowledgeof the threats overseas can begained from previous visits,from your partner organisationand through research orcontext assessment.

2. Look at patterns and trends.Where have previous incidentsoccurred? Are things changingover time? Are certain incidentsoccurring more frequently?Are certain areas becomingtoo dangerous?

3. Assess vulnerability. Identifythe priority threats; namelythose that pose real risks toyour staff, assets andoperations. The key question toask is: 'Where is our particularexposure, and why? What arethe factors that leave us ‘atrisk’?'

4. Identify ways of reducingvulnerability. Having identifiedthe factors that make your Linkvulnerable, you can then reduceyour exposure by adoptingappropriate risk managementstrategies, policies andprocedures.

5. After looking at measures totake, and how to put them inplace, assess whether theremaining level of risk isacceptable. Risk is somethingwe face all the time in our dailylife, but it is important that thisrisk is proportional to theexpected gains.


120

DID YOU KNOW?

A beginners guide to risk

Risk is the extent to which we are vulnerable to threats or:

Risk = Threat x Vulnerability

Threats may be related to security, health and safety or legal issues. Threats cannot be influencedbut vulnerability (exposure or the likelihood of encountering the threat) can be managed. Securitypolicies and practices (addressing how Link participants conduct themselves, the processes andprocedures for implementation of Link activities and personal conduct) and insurance, are allmethods of reducing vulnerability to risks. By reducing vulnerability to threats, we reduce risk:

Risk = Threat (External) x Vulnerability (Internal)

As vulnerability decreases, so does risk.

a a

G


121

f EXAMPLE

Five steps to conducting a risk assessment:

1. List existing threats, for example 'vehicle accidents'.

2. Look at patterns and trends; are certain routes, types ofvehicles (e.g. local taxis/buses) more prone to be involvedin an accident?

3. Assess vulnerability. Where will your staff be travelling byvehicle? Will they be using roads with high accident rates?Who could be affected?

4. Make it less likely that such an event will affect your staff.Ways to do this might include:• Driving more slowly• Avoiding unnecessary travel especially through'accident black spots'

• Using road-worthy vehicles• Using skilled drivers

You also need to look at reducing the potential impact ofa threat. Ways to do this might include:

• Wear seatbelts• First aid training and kits• Take out travel and medical insurance• Have a charged mobile phone with emergency contactnumbers to alert assistance quickly

5. If these measures to reduce likelihood and impact aretaken at the organisational and individual level, has therisk been reduced to a level which the organisation andindividuals are willing to accept? If not, are there othermeasures to take that will further reduce the level of riskto an acceptable one?

If still not, this particular risk could mean that you needto rethink the Link programme, or this aspect of the Linkprogramme.

2.11

REMEMBER!

Risk assessment is not justfor the UK partner.

It is important that riskassessments, and actionsto mitigate risk, are alsoconsidered for those visitingthe UK. While the risks maybe fewer, travelling to the UKcan be bewildering for thosefrom other locations andcultures, and there areparticular threats that apply.This is particularly true forinner city environments.

Visitors should be providedwith tips for living, workingand adapting to the UK, andreceive an appropriatebriefing on arrival. Healthand travel insurance needsto be considered. Overseasvisitors will only be coveredby the NHS in medicalemergencies. (Chapter 2.5looks at ways you mightmake these preparations).

DC

Risk management documentsIn addition to your organisation'srisk and security guidelines,consider creating your own Link-specific guidelines which could beincorporated into your LinkInduction Pack. All staff involvedin the Link should read andunderstand the assessments andtheir implications, and have themto hand should an incident occur.

Good risk management policiesand procedures include:

1. Key organisational principlesand responsibilities for risk andsecurity.

2. Methods for assessing thepotential risks you face,including provision for regularreview of risk assessments.

3. Actions to be taken at anorganisational level to minimizerisk. This may include training,written procedures, checklistsand key areas of responsibilityof individuals on the LinkCommittee, as well as on theBoard/ Deanery.

4. Actions to be taken by eachindividual to minimise risk.

5. Arrangements with regard toliability insurance, includingmeasures to take with regardto professional indemnityinsurance and professionalregistration.

6. Appropriate travel, professionalindemnity and medicalinsurance provision.

7. Security and conduct of staffand other stakeholders wheninvolved in travelling overseasas part of the Link.

8. Specific measures with regardto key threats identified as highor medium in the riskassessment, that need to beenforced at a policy level.

9. Procedures for briefing staffon risk and risk management.

FIND OUT MORE

THET’s Risk and SecurityGuidelines for Links can befound on THET’s website:www.thet.org.uk

Insurance as a way tomitigate riskAppropriate insurance provision isa key measure in reducing theimpact of a whole host of threats.In advance of any activity andvisits overseas, your Link shouldlook at what insurance provision isappropriate.

Beware of standard travelinsurance. Many individuals willhave their own 'worldwide'travel insurance either directly,or through bank and credit cardcompanies. These are unlikelyto cover staff adequately onLink visits as these are designedfor travel and tourism. Eithertake out specific insurancecover for individual trips or, ifyour Link is planning severaltrips a year, take out a GroupTravel Policy which covers alltravellers. Having a standardinsurance policy for everyonesimplifies procedures in theevent of an emergency.

Areas to ensure are covered byyour travel insurance, whethergroup or individual, includepersonal accident, medicalexpenses, war cover andpolitical evacuation insurance.

It is also advisable to select aninsurance policy which is linkedto a medical evacuation servicesuch as CEGA who providededicated air ambulanceservices, medical assistanceand repatriation services.

If the Foreign andCommonwealth Office (FCO)advises against travel to aparticular country, this maymean that some insurancecompanies will not cover travelto these countries. This doesnot necessarily precludeworking in this country, butdoes mean that specificinsurance may be needed forthese locations (and thepremium is likely to be moreexpensive). Check with yourinsurance broker for exclusionareas.

Specialist kidnap and hostageInsurance packages do existand are advisable if you areworking in areas with a high riskof this. They can be extremelycomplex and costly but usuallyinclude provision of skilledadvisors to assist in managingincidents of this nature.

FIND OUT MORE

Advice on insurance can beobtained from BritishInsurance BrokersAssociation (BIBA)www.biba.org.uk who canprovide details of specialistinsurance brokers. Manyinsurers also provide guidesand frameworks forconducting risk assessments.


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/

UK

Non-European residents willonly be covered by the NHS inthe case of an accident oremergency. For additionalcoverage such as private healthcare, repatriation costs and lossof personal effects, it isadvisable to get appropriatetravel insurance. You can getinformation about this fromlocal insurance brokers or travelagents.

Professional liability,indemnity and registrationAs well as considering travel andmedical insurance, it is importantthat issues related to professionalpractice – including liabilities – areconsidered and appropriate stepstaken. The following tablehighlights some of the issuesthat Links should consider.


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2.11

Vicarious Liability

ProfessionalIndemnity Cover

Students

Registration

This is a legal concept that exists in the UK and means that the employer isvicariously liable for the acts or omissions of an employee for work undertakenduring the course of that employment (since the employer has authorised theacts of the party who is at fault). This concept does not apply worldwide. Healthprofessionals should therefore check the indemnity arrangements before theyleave the UK to determine whether they need to make their own arrangementsfor indemnity.

Those visiting the UK should be covered by the NHS Trust in which they areworking, if registered (see below). Those that are not registered will only be ableto observe. Please check this with your UK partner organisation.

It is advised to contact your usual provider of professional indemnity cover priorto departure to ensure that you have adequate cover. The provider will usually beable to provide cover but this may vary depending on location and professionalgrade.

Students involved in Links should only be there on placement for observationpurposes. Students should be supervised and working under the direction of atrained professional who is both responsible and accountable for their actions.For this reason, and if this is strictly observed, indemnity insurance should not benecessary.

Depending on the activities they will be carrying out, practitioners may be requiredto register with the regulatory body for the country in which they intend to work.The General Medical Council (GMC) can provide UK doctors with contact details ofmost overseas regulators (details on their website www.gmc-uk.org). Similarly, theGMC provides information packs for doctors from overseas who are intending towork in the UK. For nurses, most countries have their own nurse registrationauthorities. Where there is no system of nurse registration, Nursing and MidwiferyCouncil (NMC) registration is valid. As nurses working for the armed forces andvoluntary organisations are exempt from this, we advise Links to contact the NMCto ascertain if registration is required for their specific programme circumstances.

For the UK, if a visiting doctor is to be practising, including prescription or invasiveprocedures, they must have registration with the GMC. For other professionals, theadvice is to check with the relevant professional body for up to date information.This is often very difficult to obtain so most Link visits to the UK just involveobservation.

BriefingIt is vital that written documentson risk and security are supportedby an appropriate briefing andinduction. When staff traveloverseas (whether this is from theDeveloping Country to the UK orvice-versa) they should receive apre-departure and arrival briefingthat covers risk and securityissues.

FIND OUT MORE

• ECHO security review andguidelines designed forhumanitarian agencies,with some relevance forLinks.

http://ec.europa.eu/echo/policies/evaluation/thematic_en.htm#security

• Further resources on riskand security managementfrom leading NGO SecurityTraining Provider. Pleasenote the web basedresources are quite outof date. More up to dateresources are available bycontacting RedR.

RedR also maintain aregister of risk andsecurity consultants, withan NGO background whocan be contracted to assistwith risk assessment.

www.redr.org/redr/support/resources/trainersResources/index.htm

• The following companiesprovide specialist riskassessment services, andhave some experience withthe NGO/Health sector.THET provides thesedetails for information,but is not endorsing theseproviders over others thatmay exist.

• Centurion Safetywww.centurionsafety.net

• Control Risks Groupwww.crg.com

• Armor Groupwww.armorgroup.com

CHAPTER CHECKLIST

} Involve those within yourorganisation who haveexpertise in this area tocreate a Link risk andsecurity policy. Get thissigned off by your Boardand Link Committee.

} Ensure that informationon managing risk is givento staff. Writtendocuments should besupported by briefings.

} Take out appropriatemedical and travelinsurance.

} Ensure that staff informtheir current provider ofindemnity insurancebefore going overseas.

} For more detailed advicesee THET’s Risk andSecurity Guidelines forLinks, available fromwww.thet.org.uk


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/ }

Health and well being– worth taking a fewmanaged risks for this.

SECTION3.Appendices

126

This section includes extra documents whichcomplement issues raised within the Manual.

Appendix 1: About THET

Appendix 2: The NHS

Appendix 3: Other organisationssupporting links

Appendix 4: Sample paper to the Board

Appendix 5: The health context

Appendix 6: Template Memorandum ofUnderstanding (MoU) for a Link

Appendix 7: Links report template

Appendix 8: Resources in health information

Appendix 9: Sample donor mapping excercise

Appendix 1.About THET

128

THET was established in 1988 by Professor Eldryd Parry, who spent much of his career helping to set up medicalschools in Africa. After his return to the UK he was concerned with the paradigm shift in overseas aid which meantthat support to health training schools was no longer a priority. But how could countries expect to deliver basic healthservices without adequate human resources?

THET’s start was modest – putting standard text books into medical schools. But soon requests came in to helpdevelop the skills and experience of young graduates and to support neglected subjects such as epilepsy, diabetes andmental health.

THET drew on expertise from within the UK to support these requests, running surgical skills courses for youngmedical officers in Ethiopia and supporting psychiatric training in Kampala, laboratory skills training in northernGhana, and students’ community work in Malawi. THET’s underpinning philosophy has always been to respond torequests.

Then in 1998 the first major THET Link was started. The Chief Executive of Nottingham City Hospital visited Jimma,Ethiopia, with THET to see what more Nottingham could do. It was evident that this model of a Link would developwhole organisations and would be broader than only concentrating on one disease. The focus of the Link would be thegoals of health workers and UK staff could work towards supporting colleagues at Jimma.

With funding from the Lottery in 2000 four new Links across Malawi, Ghana and Ethiopia were developed andsupported. This enabled THET to pull together good practice in Links, through working closely with them andunderstanding their opportunities and constraints.

Since 2005 THET and Links have become more ambitious. There are now 100 Links making a wider impact than ever.THET exists to help them make a strategic difference and get the support they need to do this. This Manual is part ofTHET’s efforts to help Links learn from the experience of others and achieve the maximum impact.

www.thet.org.uk

Ap.1

Appendix 2.TheNHS

129

The NHS was established in 1948 as a free and comprehensive health care service available to all. The NHS is thelargest employer in the UK and Europe, employing approximately 1.3 million staff. It provides an enormous range ofservices to over 57 million people and in 2008 the annual budget was over £100 billion. The NHS is undergoingconstant reform to improve quality and standards of care offered and enable greater patient choice.

The structure of the NHS differs in each of the administrations within the UK (England, Wales, Scotland and NorthernIreland) so if you are linking with an organisation in one of these countries you will need to find out how the structurediffers in those countries. THET can help you with this.

In England, the Department of Health, a Government department, is responsible for improving the health and well-being of everyone in England. It provides strategic direction for health and social care services, secures resourcesfrom Parliament funded through general taxation, develops policies, sets national standards and invests in the service.

The whole of England is split into 10 Strategic Health Authorities (SHAs). These organisations were set up in 2002 todevelop plans for integrating national priorities into local health delivery plans, to improve health and health servicesin their local area and to make sure their local organisations are performing well.

Primary Care Trusts are at the centre of the NHS and receive funding from the Department of Health to assess thehealth needs of local people, planning and buying (commissioning) the health care that is needed. They negotiatecontracts with NHS and Foundation Trusts and other non-NHS providers for the provision of care. They also contractwith doctors, dentists, pharmacists and optometrists for the provision of primary care services – the services providedby people you normally see when you first have a health problem. They are responsible for getting health and socialcare systems working together for the benefit of patients. There are about 150 Primary Care Trusts in Englandmanaged by Boards and accountable to the SHAs.

The provision of services within the NHS is undertaken by two different types of trusts which employ a large part ofthe NHS workforce. NHS Trusts and Foundation Trusts:

• NHS Trusts are run by Boards of Directors and are accountable to the SHA and provide a range of NHS services.Some NHS Trusts provide acute and planned care based in hospitals and outpatient clinics, some provide mentalhealth care and some provide ambulance services.

• Foundation Trusts are a relatively new type of NHS organisation run by local managers, staff and members of thepublic. Foundation Trusts have been given much more financial and operational freedom than other NHS Trusts andhave come to represent the government’s commitment to de-centralising the control of public services. TheseTrusts remain within the NHS and its performance inspection system but are licensed and regulated by a separateindependent body called a Monitor.

Some Trusts are regional or national centres for specialised care. Others are attached to universities and help to trainhealth professionals. Some Trusts, called Care Trusts, work in both health and social care and usually provide mentalhealth services. All Trusts receive the majority of their income from contracts with Primary Care Trusts for theprovision of health service. A

p.2

The UK Government is about to fund a 'one-stop-shop' information centre for Health Links. This is to be based at theLiverpool School for Tropical Medicine.

There are also a number of specialist Link organisations which can support and network Links working to supportparticular areas. These are detailed in first table below.

In the USA, Canada and Europe other umbrella organisations exist which support health partnership and Links.These are detailed in the second table. This information is most useful for DC partners interested in linking with non-UK organisations.

THET believes that Health Links should be ready to collaborate with, and learn from, twinning bodies in subject areassuch as science and technology, education, community and local government Links.

BUILD (www.build-online.org.uk) is the UK umbrella body for twinning and linking across different subject boundarieswithin which THET is the health sector leader. The Africa Unit at the Association of Commonwealth Universities(www.acu.ac.uk) is the key organisation providing support to higher education and further education partnerships,while UKCDS (www.ukcds.org.uk) offer support for science based research (although the establishment of Links is notits main remit).

Appendix 3.Other organisationssupporting Links

130

Ap.3

SPECIALITY

Palliative care

Ophthalmology

Urology

SUPPORT PROVIDED

Supports members and other organisations as they strive to growand improve end of life care throughout the UK and across theworld.

Help the Hospices international programme supports thedevelopment of hospice and palliative care worldwide, particularlyin developing countries. They believe that everyone living withlife-limiting illness has the right to quality, affordable care.

Identifies overseas partner based on priority need and matcheswith suitable UK organisations.

Facilitates the needs assessment process – team visits to overseasorganisations and return visit of teams from partner Links to theUK.

Facilitates development of a detailed three year activity plan anddevelopment of the Memorandum of Understanding anddevelopment of steering group.

Supports the ongoing Link; and provides advice on fundraising,monitoring and evaluation.

Urological overseas Links for the promotion of urological care andeducation Worldwide.

UROLINK represents the British Association of Urological Surgeonsin the developing world.

Promotes the provision of appropriate urological expertise andeducation worldwide.

Encourages the development of training opportunities and providesadvice to overseas trainees.

Coordinates the development of Links as defined by BAUS Councilwith both national and international urological associations in the'developed' world, for example with Europe and North America.

ORGANISATION

HospiceInformation

www.hospiceinformation.info

Vision 2020 LinksProgramme

www.vision2020uk.org.uk

Urolink

www.urolink.org

Organisation providing specialist support to Health Links


Appendix 3.Other organisationssupporting Links

131

SPECIALITY

Medicallibraries

Telemedicine

SUPPORT PROVIDED

Facilitates partnerships between health libraries in the UK andthose in developing countries.

Builds the capacity of librarians and other health informationprofessionals to develop innovative information services.

Works collaboratively with others to increase the flow of timely,reliable and appropriate health information.

The Swinfen Charitable Trust was set up by Lord and Lady Swinfenin 1998, with the aim of assisting poor, sick and disabled people inthe developing world.

The Trust's policy is to do this by establishing telemedicine Linksbetween hospital-based practitioners in the developing world andexpert medical and surgical specialists who generously give freeadvice via the internet.

ORGANISATION

Partnerships forHealth Information(PHI)

www.partnershipsinhealthinformation.org.uk

Swinfen CharitableTrust

www.swinfencharitabletrust.org

COUNTRY

USA

Canada

Norway

Europe

SUPPORT PROVIDED

This is a consortium of health care organisations whichcontributes to health systems strengthening in developingcountries through international health partnerships betweenmembers of the consortium and organisations in developingcountries.

Provides education and training to medical, dental, andnursing students in Latin America and the Caribbean byfacilitating partnerships between their own staff as well asthose from medical, dental, and nursing schools in the U.S.,and counterparts in Latin America and the Caribbean.

Its goals are to mobilise greater Canadian investment andinvolvement in global health research, nurture partnershipsbetween Canadians and health researchers in low- and middle-income countries, and use research to take action in globalhealth.

FK’s mission is to improve the economic, social, and politicalsituation of developing countries by fostering cooperationbetween individuals and organisations in Norway and theircounterparts in developing countries.

A Europe-wide network of governments aiming to buildcapacity for HIV/AIDS treatment in developing countries byfollowing the twinning methods used by the Frenchorganisation ESTHER. Each country has designated a specificorganisation or agency to manage its ESTHER activities.

ORGANISATION

Center for InternationalHealth

www.centerforinternationalhealth.org

Hope for a HealthierHumanity

www.hopeforahealthierhumanity.org

Canadian Coalition forGlobal Health Research

www.ccghr.ca

FK Norway

www.fredskorpset.no/en

Alliance ESTHER (Europe)

www.esther.eu

Organisation providing specialist support to Health Links

Ap.3

Appendix 4.Sample paperto the Board

132

(Draft Paper to an NHS Board to support an international health Link)

__[insert name]__ NHS Trust

A Proposal to establish/strengthen an Overseas Health Link with __[insert name]__

Introduction

This paper sets out a proposal to establish/strengthen an international health Link between (insert UK organisation) and(insert overseas partner). It sets out the mutual benefits of a Link and seeks Board approval to proceed with/further

develop an organisational Link

Background

UK Government attention to global health has recently increased with the publication of ‘Health is Global: Proposals for aUK government-wide strategy’ by the Department of Health (2007) and ‘Global Health Partnerships’ in which Lord Crispoutlines the principles and rationale for NHS involvement in international partnerships, and emphasises the benefits forthose in the UK. He emphasises that most organisations will be able to fund this activity up to the limit where they believethere is mutual benefit in learning, staff development and the exchange of skills as well as benefits to their reputation.He suggested that the Health Care Commission (HCC) should be asked to include the contribution to internationaldevelopment in its annual assessment process. A response to the report was published in March 2008 and includes acommitment to finance a UK Centre for international health partnerships, a grant scheme for Links worth £1.25m per yearfor three years and an independent evaluation of Health Links that will influence the priorities for the grants scheme.

Many NHS organisations have already set up Links and joined partnerships with projects in developing countries. Theprocess of developing Links is supported by the Tropical Health and Education Trust (THET). THET is a UK based charity,funded by the Department of International Development and supported by the Department of Health, and aims tostrengthen health services of the poorest countries, especially in sub-Saharan Africa, through developing Links betweenhospitals and services and UK health care organisations. The aim is to build long-term capacity through training andsupport for front-line health workers.

There are already over 80 Links between NHS and overseas organisations, many of which are making a real difference tothe health and health services of some of the poorest countries. Links have been made between Trusts of many differentvarieties including mental health and partnership trusts, PCTs, Foundation Trusts and NHS Trusts in conjunction with theirlocal Medical School/University. There are many different ways of organising and funding Links, including King’s CollegeHospital Foundation Trust which has established an international office, Links funded to support the professional andpersonal development of UK health staff and many Links which are established as charities and raise funds to supporttheir work.

Some examples are:

• Birmingham Children’s Trust which is supporting training of paediatric staff in the Queen Elizabeth Hospital, Blantyre,Malawi

• East London Mental Health Trust has established a Link with Butabika Hospital in Uganda supporting training insubstance misuse, child and adolescent health and the psychological consequences of trauma. Much work is focused ontraining clinical officers, school graduates who have basic clinical medicine training.

Establishing an International Health Link

It is proposed to establish/strengthen a Link between (insert NHS organisation) and (insert overseas partner) in (insertcountry). The population in xx is xx million and the average life expectancy is xx years with an under 5 mortality rate of xxper 1000. (insert other, relevant detailed info). The Ministry of Health in xxx is supportive of a Link with xxx because xxxx .Although a more formal needs assessment would be undertaken at an early stage in the development of a Link, theexpressed hope by the overseas partner is for the expansion and improvement of xxxxx services and xxx. A successful Linkrequires long term collaboration and mutual knowledge and agreement of both what is required and what is possible todeliver.

Benefits to (NHS organisation) and its staff

Establishing an international Link will bring the following benefits for the Trust and its staff by:

• Providing personal, professional and leadership development opportunities (regarded by many as better than attendingtraditional training courses);

Ap.4

Appendix 4.Sample paperto the Board

133

• Learning new administrative and management skills;

• Giving staff a new perspective on their UK work having worked in a resource poor environment;

• Imparting a sense of contributing to sustainable development in a situation where it is possible to make a real difference;

• Acquiring skills in managing disorders and presentations rarely seen in the native UK population but potentiallyincreasing in the diverse community that now comprises the population served;

• Building resilience and confidence in tackling new challenges;

• Providing a tool for recruitment and retention, motivation and refreshment of staff;

• Bringing staff together to work for a common cause;

• Enhancing the national and international reputation of the Trust and fulfilling a moral and corporate social responsibilityin the light of the NHS history of recruiting health professionals from overseas;

• Learning about and understanding other cultures – this knowledge is often of great value in furthering understanding ofother cultures in the UK context, especially given the expansion of a global workforce in the NHS and serving therefugee or expatriate communities under the Trust’s care;

• Contributing towards the achievement of the equality and diversity agenda.

Costs

Costs would include that of employees’ time and supporting visits in both directions - UK staff to Link project or vice versa.Within other well-established Link projects, time has been taken as study or special leave supplemented by annual leave.THET advises that the major cost lies in supporting exchange visits, and is £15,000 - £20,000 per annum. Most Linkprojects support this by money raised through payroll giving, grants, local travel awards and fundraising activities.

Next Steps

The next steps in proceeding with the Link are: (some or all of these may be relevant)

• To identify a coordinator for the Link and form a Link Committee consisting of _[insert who will be on the Committeeand consider asking for a Board level Director or non exec director to be a member]_

• To conduct an initial visit to xxx to meet partners, get a sense of the place, conduct a risk assessment, understand thepartner’s needs and agree objectives for the Link in terms of providing strategic support to build capacity for the longterm;

• To establish fundraising activities to support the Link;

• To identify staff in the Trust who are interested in contributing to the development of _[insert]_ services in _[insert]_

• To agree human resources policies in relation to the activities of the Link

• Agree governance and reporting procedures with the Trust

Conclusion

We believe that there is a strong case for the development of such Links and this has been accepted as part of governmentpolicy moving forward. Links should take place with the backing of organisations, rather than individual efforts, in order toensure sustainability and accountability. The potential for mutual benefit is substantial, and we hope that our Trust willconsider our proposal to investigate the possibility more fully. We would be happy to meet to discuss this further, and topresent in more detail issues outlined above, as well as details of the work of other Trusts, already engaged in Links.

The Trust Board is requested to:

• Give formal recognition to the Link and staff involvement in it, on the basis that this will be of benefit to both the Trustand overseas partner and their staff;

• Develop a policy to support staff undertaking work overseas (for example special paid leave, funding immunisationcosts);

• Supporting reciprocal training visits (for example by providing accommodation for overseas visitors);

• Support fundraising initiatives within the Trust

• _[ insert any other requests to the Board]_

Names of authors Date

Ap.4

Appendix 5.The health context

134

You will need an understanding of the health economy in the country you are linking in. How is health provision structured?

What expertise and resources are available? How is health funded? Where are the main challenges? The following tableshighlight some issues you will need to be aware of.

Link participants should also understand the political climate of their partners country, governmental structure, availabilityof resources, local culture and any specific local challenges.

KEY TERMSHealth Sector Wide Approach (SWAp): a coordinated donor approach whereby funding from different donorsis pooled to promote increased health sector coordination, stronger national leadership and ownership, andstrengthened countrywide management and delivery systems. SWAp is a government approach which providesthe Ministry of Health with the leadership and only funds activities in the national health sector plan. Donorfunds are pooled and earmarked for high priority activities, such as essential health packages (e.g. Uganda,Tanzania). It replaces traditional project-centred approaches to funding.

Health Systems Strengthening: any strategy for strengthening health systems needs a basic shared perceptionof what a health system is, what it is striving to achieve, and how to tell if it is moving in the desired direction.Source: World Health Organisation (WHO), 2007

International Health Architecture: the network of international organisations and internationally agreedarrangements designed to improve health and aid modalities This will include bilateral donor organisationse.g. (USAID, GTZ, DFID, JICA), multilateral organisations (UN, WHO, EU) and NGOs (Save the Children, etc).

Vertical Health Programme: a programme aimed at countering specific diseases often promoted by donor andaid agencies. These have come under scrutiny in recent years become they do little to strengthen healthsystems as a whole. The general move now is towards health system strengthening.

FIND OUT MORE

Find out the following from your DC partners:

• What are the priorities? Look at the key health policy documents for your partner’s country. Is there anEssential Health care Package? Health Sector Strategic Plan? What are the national challenges andpriorities? This will help you to better understand the needs that your partner identifies and ensure thatthe work is aligned to national priorities (remember the Paris Declaration on page 33). Perhaps your Linkcan help deliver training that has already been identified on Implementation Plans.

• What is the health aid architecture? Who are the main donors, what they are addressing and how?If funding is through a SWAp, local districts will have more authority to determine their needs.Can you help feed into this?

• Is health care decentralised with authority devolved to the districts? What powers does the Ministry ofHealth have and what do District Headquarters do? This will determine who the key people you need tospeak to are.

• Is health care free of charge or do people have to pay a user fee? Are drugs free or charged?This will determine how early people present to health facilities and how busy they are.

• What are the key cadres of health workers? Many countries have mid-level cadres of health workers,such as Clinical Officers and Medical Assistants, which often carry out the work of doctors in rural areas.They take less time to train than doctors and, in many cases, retention levels in rural areas are better.

• Who are the patients? The socio-economic situation of patients will often determine the issues which arepresented.

Ap.5

UK

UK


135

Doctors:Patient Ratio

Nurses:Patient Ratio

Public HealthServices

Funding ofHealth Services

DEVELOPING COUNTRIES

1 : 48,000 (Malawi)

1 : 4500 (Ethiopia)

Structural Adjustment Programmes (SAPs)imposed in the 1980s by the World Bank andInternational Monetary Fund meant thatmany countries had to cut back on publicservices, including health and educationservices, to pay off their debts.

The consequences? Patients being chargedfor services, hospital cut backs, fewer healthworkers trained and rising ill health. With therealisation that there is a close associationbetween health and poverty, public healthservices are now back on the agenda andmany countries are beginning to provide freehealth care. Following the Gleneagles G8summit in 2005 the writing off of debt hasmeant that some countries, such as Zambia,no longer charge user fees in health facilities.Many challenges still exist including severeshortages of health workers and resources.

Many countries currently have an active NGOsector providing additional health services.For example the Christian Health Associationof Malawi (CHAM) is the umbrellaorganisation for Christian owned healthfacilities and provides 37% of the healthservices in the country.

Government budgets are small and healthspending is often topped up through bilateraldonor (e.g. DFID, JICA, GTZ) budget support.Revenues from taxation are small due to alarge informal economy. This makes it difficultfor the governments to plan and budget inthe long term.

Some countries have developed HealthSector Wide Approaches (SWAp) whichcoordinate all donor funding for health anddecentralise power within countries.

Many countries still charge user fees forhealth facilities although the trend is towardsfree services, especially for mothers andchildren. Many countries are exploringdifferent options such as health insuranceand public-private partnerships.

A context comparison…

Ap.5

UK

1:450

1:80

There is a publicly funded health system inthe UK, referred to as the National HealthService (NHS), which was established in 1948.The NHS provides the majority of healthservices in the UK and is the largest employerin Europe.

The NHS holds a vast range of expertise andproviders range from GP practices to teachinghospitals and specialist Trusts providingreferral services. A DC organisation linkingwith an NHS facility will need to think aboutwhich type of NHS institution matches theirrequirements most closely. Refer to Appendix2 for an overview of the NHS.

The UK is a welfare state and has a publiclyfunded (through taxation) health care systemwhich is free at the point of delivery, althoughprivate service providers also exist.


Note that this section will not be an accurate representation of all countries and makes some broad generalisations


136

Humanresources forhealth

Clinical training

Healthpriorities


There is a critical shortage of humanresources in health. This has been causedby a combination of:

• Brain drain to developed countries,

• Low output of trained health workers,

• Loss from the systems due to negativework environment, low salaries, death, etc

• Recruitment into NGOs and otherdevelopment partners.

Expat doctors, primarily from Cuba, Egypt,Europe and America often fill gaps wherethere is a shortage of local doctors. This cancreate language and cultural problems andcreate problems for long-term sustainability.

Emergency plans are being made toincrease training output and build thecapacity of the human resource base (seep16 on 2006 WHO Report). These need to bebacked by international reinforcement. Butretention, motivation and professionaldevelopment of staff are still some of thekey challenges. Links may be able to play arole in this.

Some countries may only have one medicalschool with a small yearly output of doctors.

Due to the extreme shortage of doctors andtheir unwillingness to stay in rural areas,many countries have been training midlevelhealth professionals (e.g. health officers inEthiopia) to fill this gap. These healthprofessionals are trained in basic medicalsciences, public health and clinical medicineand are usually responsible for deliveringhealth care in rural health centres andhospitals.

Nurses also play a very important role in thedelivery of services. However a commonchallenge is bridging the gap betweentheory and practice.

High burden of chronic, communicablediseases and trauma-related deaths anddisabilities. Many preventable illnesses arenot being addressed due to shortages ofhealth workers and weak systems.

Some development approaches, such asvertical health programmes focusing solelyon issues such as HIV, have inadvertentlyweakened health systems.


UK

In the past health worker output from UKtraining schools has not been sufficient tomatch demand (although now output isgreater than demand). This resulted inrecruitment drives for health workers fromoverseas and many health workers fromAfrica and Asia migrated to work in the UK, tothe detriment of their own countries.

In 2004 these recruitment drives werestopped. The UK has increased the trainingcapacity of its medical and nursing schools.Tougher immigration rules are having adeterrent effect. Links are a way of puttingsomething back.

Global ethical recruitment code on its waywww.who.int/workforcealliance/about/taskforces/migration/en/index.html

Training of health professionals takes placewithin universities that work closely withteaching hospitals.

All health worker training schools, be it fornurses, doctors, midwives or dentists, areincorporated within universities. All mattersrelating to admissions, the curriculum,learning resources, teaching qualityassurance, student welfare and examinationsare the responsibility of the university. Someof the teaching however, particularly theclinical elements of the course, is devolved toNHS Trusts. Each university is linked with oneor more large teaching hospitals, but studentsalso receive instruction at district generalhospitals, mental health trusts, and in GPpractices.

High burden of chronic diseases and anageing population. Focus on patient-centredapproaches.


Ap.5


137

Privatehealth care

Traditionalhealth care

Find out more


The crisis of public health provision hasresulted in the emergence and expansion ofprivate health services. These may be localprivate providers or international providersand offer both generalist and specialistservices. There is very little regulation in theprivate sector causing concern over thequality of some services provided byindividually run private clinics.

Private hospitals tend to be well resourcedand often have good facilities and levels ofcare but high costs inhibit the majority of thepopulation to access these services. If a Linkrequest is made from a private providerconsider whether they provide free servicesto children or patients who cannot afford careand whether the work of the Link wouldbenefit this group of people.

In many African, Asian, and South Americancountries traditional medicine is widely usedand helps to meet some of the primary careneeds. In Africa up to 80% of people usetraditional medicine. Some collaboration mayoccur between traditional healers andwestern medicine practitioners, particularly inprimary care. For example in some countries,traditional birth attendants rather thanmidwives will assist in the majority of births.

World Health Organisation (WHO) is thedirecting and coordinating authority forhealth within the United Nations system. It isresponsible for providing leadership on globalhealth matters, shaping the health researchagenda, setting norms and standards,articulating evidence-based policy options,providing technical support to countries andmonitoring and assessing health trends. Ifyou are contributing to the development ofprotocols or guidance you should refer toWHO samples.

www.who.int

The Ministry of Health of your partner’scountry will have key documents which youwill need know about.


UK

Private hospitals exist in the UK for those whoare willing to pay for their treatment, but itrepresents less than 10% of the UK healthcare and is used largely to top-up services.Generally speaking Links are with NHSorganisations and there is little interactionwith private health care providers.

In the UK adaptations of traditional medicineare termed ‘complementary’ or ‘alternative’medicine. Many stem from traditional Chinesemedicine or alternative therapies. The NHSsometimes includes certain alternativeapproaches, such as acupuncture, in itsprovision, but most services of this kind aresought and paid for on an individual basis andare not involved in Links.

www.nhs.uk gives you access to the NHSportal where you can find out about differenthospitals, the services they offer and the keyconsultants working there.

www.ucas.ac.uk you can search undermedicine, nursing, midwifery and the differentallied health professions to find a list of alluniversities in the UK offering health courses

The British Medical Association (BMA)www.bma.org.uk

The Medical Royal Colleges, the Royal Collegeof Nursing and the Royal College of Midwidery

)

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Appendix 6.TemplateMemorandumof Understanding (MoU)for a Link

138

Many Health Links choose to sign a Memorandum of Understanding (MoU), either at the start of the Link or to formalisethe work of an existing Link. Developing an MoU can be an important way to ensure that both partners agree on thebroad purpose of the Link, as well as setting out how the two sides will work together. An MoU can encourage a greaterfeeling of ownership by both partners – provided that the process of developing and drafting the MoU is a truecollaboration, rather than being driven from the UK.

Some Links choose to write a brief one-page MoU, while others prepare a more formal and lengthy document. Thefollowing relatively short example is based on a range of MoUs developed by real Links. It is intended to serve as anexample only – please ensure that any MoU you sign has been adapted to fit with your specific needs and that it alsomeets the laws and regulations of any relevant bodies operating in the countries involved.

MEMORANDUM OF UNDERSTANDINGBetween XXX and YYYDated xxx

1) Introduction

Organisation XX and Organisation YY hereby agree to develop aHealth Link (known as 'the Link') between both organisations, withthe aim of fostering cooperation and the exchange of knowledgeand skills in the areas of: xx and xx

Organisation XX and Organisation YY share the belief thatexchanges of skills and experience are an important resource in:

• Supporting improvements in health services and systems indeveloping countries,

• Bringing personal and professional benefits to health workers inthe UK and,

• Enhancing solidarity between those from different countries.

We acknowledge, therefore, a mutual interest in working to supporthealth systems and in building the capacity of health workers incountry xx.

We share a commitment to the following key principles. We will:

• Respond to priorities identified by Organisation XX (the‘southern’ partner), in dialogue with Organisation YY.

• Ensure that the Link focuses on areas where there is ademonstrable health care need, or need for health systemstrengthening.

• Ensure that the activities of the Link are in alignment withnational and local healthcare priorities and plans in country xx.

The agreement to form a Link has the full support of the Board atOrganisations XX and YY (following meetings on xx).

2) Purpose of the Link

The Link will encompass:

• xx

• xx

• xx

COMMENTS:

Example areas of knowledge and skillse.g. education, clinical practice, training,working practices, technologies, healthsystem strengthening, research.

As well as Board support, some MoUsalso mention relationships with DFID,Royal Colleges, THET or othersupporting organisations here.

This should describe the main purposeor broad aims of the link

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Appendix 6.TemplateMemorandumof Understanding (MoU)for a Health Link

139

3) Alignment

In line with the 2005 Paris Declaration on Aid Effectiveness, weacknowledge the importance of ensuring that the Link is in alignmentwith the health care priorities and plans of the Ministry of Health incountry xx, and with local health plans for region xx.

We will therefore make every effort to ensure that all activities of theLink are in line with current health care plans.

This has been discussed with the Ministry of Health in country XX(during meetings on xx dates).

4) Coordination, roles and responsibilities

Each organisation will establish a (describe group eg Steering Group,Link Committee) to coordinate the work of the Link. The group willmeet (frequency), and will comprise the following people:

For Organisation XX [ ] For Organisation YY [ ]

The key roles and responsibilities for the (Steering Group/LinkCommittee) will be:

• xx

• xx

Key contacts: In addition, we nominate the following staff as LinkCoordinators, who will be the normal initial contact points forinformation or action points for this Link:

For Organisation XX [ ] For Organisation YY [ ]

The specific roles and responsibilities of the Link co-ordinators willbe:

• xx

• xx

Ways of working together: In carrying out the roles andresponsibilities described in this section, each side agrees to workwith consideration for the other and to foster mutual respect.

5) Communications

Our preferred methods of communication are: xx

All communications regarding the activities of the Link will normallybe copied to: xx

Reference could be made here tospecific local or national health planseg a national xx-year health plan, orBasic Health Package, where available.

This section could also discuss howupdates will be provided to the Ministryor other official bodies, if these havebeen requested.

Roles and responsibilities can include,for example, communications withpartners, fundraising, and publicity aswell as development/review of plans.

Having named contacts can be a usefulway to make clear who is the first ‘pointof call’ – but see Chapter 2.3 oncommunication, for suggestions onbroadening communications as a wayto avoid bottlenecks.

Specific issues of importance to yourparticular Link relationship could bementioned here. To give one example,you might like to agree to arrange visitsso that they are convenient for bothsides and do not coincide with the 'novisit' periods of the host organisation,where these exist.

Specify here if email, phone, fax or postis preferred. This can help prevent thecommunication difficulties that canarise when, for example, one side reliesheavily on email, while the other side –with less reliable ICT – prefers phone orpost, and checks email only rarely.

It can be useful to copy communicationsabout the Link to several people; thiscan help prevent delays when, forexample, one person is away or hasemail difficulties. Unanswered emailsand letters can quickly lead tofrustrations.

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140

6) Planning, development and activities

We are committed to the principle of responding to the prioritiesidentified by Organisation XX (the southern partner), in dialoguewith Organisation YY.

We acknowledge that planning is most effective when there is inputfrom a range of people from both Link partners - and from otherstakeholders.

(For a new Link)

Before specific activities begin, the priority needs will be identifiedand agreed. Both sides will work together to agree overalloutcomes and to prepare a detailed (costed?) plan of activities (forxx years?), including estimates of the required resources (includingstaff time).

The process for development and review of these plans will be: xx

(For an MoU formalizing an existing Link:)

This MoU recognizes and encompasses the existing activities takingplace between the organisations, including:

• xx

• xx

In addition, Organisation XX has identified the need for xx and xx.As a result, new outcomes that will be established under the Linkinclude:

• xx

• xx

These will be delivered through the following outputs and activities:

• xx

• xx

The process for development and review of these plans will be: xx

7) Monitoring and evaluation

We are committed to tracking our progress regularly, to learningfrom our experiences, and to sharing this information with eachother – and with other organisations that might benefit.

Monitoring

Regular monitoring of the Link’s activities will be carried out in thefollowing ways:

• xx

• xx

Evaluation

Specific activities and visits will be evaluated (when? How often?)and each partner will provide feedback to the other.

For guidance on planning, andprogramme design, please refer to thefollowing THET resources:

• Chapter 2.2 of this Manual.

• The Monitoring and EvaluationToolkit (see p89).

For both new and existing Links

Will detailed activity plans bedeveloped? Will they be costed? Howmany years will these plans cover?

You might like to have an activity planattached to the MoU as an Appendix.

Describe the role of Link Committees,panels or others involved in developingand reviewing plans here – or refer toSection 4

For both monitoring and evaluation,consider –

- What data will need to be collected?

- How will it be collected?

- How often?

- How this will analysed and reviewed.

For each item it will be helpful to agreewho will carry out the work, and whenand to check that this is realistic.For detailed guidance please refer toTHET’s forthcoming Monitoring andEvaluation Toolkit.

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141

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8) Entry into effect, amendment and termination

This MoU shall come into effect from the date of signature by theheads of the two organisations involved. This MoU shall continue ineffect, with modification by mutual agreement, until it is terminatedby either party.

9) Duration and review

We shall review the operation of this MoU in (xx months or years)after its signature. At that time, we will consider how well the MoU isworking and review progress; we will consider whether the MoUshould be extended – and if so, what further deliverables should beidentified.

10) Additional sections

Other sections that you might like consider adding to your MoUinclude:

• Settlement of disputes

• Confidentiality

• Auditing – including frequency, and who will cover the cost of this

• Visits – including agreement over appropriate timings for visits,and who will cover the costs

• Financing – eg, estimating total costs per year and detailing howthis might be met – perhaps with a disclaimer for the UK side in theevent that they are unable to raise sufficient funds

11) Signatures

This MoU is signed by

For Organisation XX: [name, signature, date]

For Organisation YY: [name, signature, date]

Appendix 7:Links report template

142

VISION 2020 Links Programme Report Template

DATE OF VISIT:

LEAD:

LINK PARTNERS: AFRICA: UK:

Brief description of the Link

Link project’s overall objectives

Activities undertaken during the visit (training etc):

Activity Date Lead Who and Outcome Assessment Follow-upperson how many

took part

Were any barriers or problems encountered and if so how were they overcome?

What benefits did the project bring to individuals and the communities overseas?

What professional benefits did the team members gain?

What future activities are planned?

Activity Date Lead Who will Outcome Assessmentperson take part

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Appendix 7:Links report template

143

REPORT TEMPLATE EXAMPLE

LinksProgrammeReportExample

Activity Date Lead person, Who and Outcome Assessment Follow-upcarried out UK & Africa how many

took part

PLANNED FUTURE ACTIVITIES

LinksProgrammeReport

Activity (includes Proposed Lead person, Who and how many Expected Assessmentfollow-up from Date UK & Africa are expected to outcomeprevious visits) take part

Ap.7

Appendix 8.Resources inhealth information

144

Contributed by Partnerships for Health Information (PHI)

There is a plethora of resources and this list is highly selective. It is worth bearing in mind that the most valuable resourcewhen searching for health information is often a person, who may be a health care professional or a health informationspecialist/librarian, so first make sure you are linked into a network of people interested in health information.

People

HIFA2015 (Health care Information for All by 2015) is a campaign and knowledge network with more than 2000 membersfrom 135 countries Worldwide. Members include health workers, publishers, librarians, information technologists,researchers, social scientists, journalists, policy-makers and others who all work together towards the HIFA2015 goal- By 2015, every person worldwide will have access to an informed health care provider.

HIFA2015’s lively discussion forums are demonstrably assisting collaboration and knowledge sharing. Olayinka Ayankogbe,Medical Lecturer, Nigeria wrote on 13 Jan 09:

"…Via HIFA2015, I have been able to talk to leading and top officials of governments, funding agencies, NGOs, leadingacademics from over 10 countries including the US, Canada, UK, Australia and leading information experts from India!The HIFA2015 network is simply wonderful. I have made contacts with top brass in WHO… I have become aninternational and global contributor to health Issues…Please join this network! Especially if you are a doctor ininformation-starved Africa!”

For more information and to sign up go to www.hifa2015.org

Books

A good source of tried and trusted textbooks is Teaching Aids at Low Cost (TALC) whose core objective is to provide freeand low cost health care books and accessories to educate people across the World. TALC offers many essential texts in awide range of areas including tropical medicine, HIV/AIDS, nursing, surgery and child health. www.talcuk.org

TALC also distributes large quantities of high quality and relevant electronic health information free to health care workersin developing countries through its eTALC CD-ROM service suitable for those with computer, but no internet access.Resources include journals, books, newsletters and interactive educational content, donated by a variety of NGOs,publishers and individuals involved in health and development in developing countries. Some of the organisations whoregularly contribute material to e-TALC include the World Health Organisation, the British Medical Journal and the Lancet.

Past issues of e-TALC are available on the website www.talcuk.org/etalc/past-issues.htm

Journals

HINARI Access to Research Initiative, a WHO programme, is the premier electronic-journal resource available todeveloping countries. The HINARI Programme was set up by WHO together with major publishers and enables manydeveloping countries to gain access to one of the world's largest collections of biomedical and health literature. Over 6200journal titles are now available to health organisations in 108 countries, benefiting many thousands of health workers andresearchers, and in turn, contributing to improved world health. www.who.int/hinari

Tropical Doctor is a journal aimed specifically at developing countries and includes information on the prevention,management and treatment of prevalent diseases in tropical and developing countries. Contributions tend to be practicalrather than academic and span a wide range of subjects.

Databases

PubMed: MEDLINE is the premier database covering medicine and health journal literature, which is produced by theNational Library of Medicine (NLM) in the U.S. PubMed is its free search interface and is used by HINARI to provide accessto MEDLINE www.ncbi.nlm.nih.gov/pubmed/

Cochrane: This database offers free access to the abstracts and, where available, the plain language summaries of allCochrane systematic reviews. Links to the full-text versions are available on each page. www.cochrane.org/reviews

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Appendix 8.Resources inhealth information

145

Websites

Essential Health Links provides a gateway to more than 700 selected websites of interest to health and informationprofessionals and researchers, publishers, and NGOs in developing countries. The gateway is hosted by the non-profitorganisation SatelLife/Academy for Educational Development (USA).

The Essential Health Links gateway www.healthnet.org/essential-Links provides a general overview of what textbooks andteaching aids are accessible via the Internet. It contains 3 main sections including; General Resources (e.g. search engines,research networks, disease classifications, evidence based medicine, full-text E-books, image collections, WHO sites anduseful email lists); Subject Index (e.g. HIV/AIDS, Public Health and Tropical Medicine and Infectious Diseases etc.); plusLibrary and Publishing Support (e.g. Internet Skills and Publishing Tools).

And finally don’t forget to talk with, and involve local librarians at both ends of the partnership in helping you. Librariansand libraries make a vital contribution to health and health care.

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Appendix 9.Sample donormapping exercise

146

Ap.9

Elements of a donor mapping exercise (sample)

Constituency Potential donor

Trust Board

Charitable Fund

Colleagues/staff

Patients, localresidents etc.

Events

Charitabletrusts andfoundations

Health Linkspecific grants

Educationstream grants

Method ofapproach

Will they considersupporting thework of the linkfinancially?

• Are thereresources withinthe institution(eg hospital’scharitable fund)that can be usedto support theLink?

• If not, can thecharitable fund(ie charitynumber) be usedas a vehicle forfundraising?

• Payroll giving

• Involvement inevents

• Involve in events

• Communicatenews of Link vianewsletter etc

• Many differentpossibilities

• Appeal writing

Cons

Initially admin-heavy inset up

Some events can be timeconsuming and may involveconsiderable up-front costs

As above

• Takes time for return(trustees meetings canbe monthly, quarterlyor annually)

• Usually only smallunrestricted grants(up to £1k)

• Usually have strictcriteria about what theywill/will not fund

• Often prefer grantee tohave charitable status

• Admin-heavy activity(research, appeal-writing,follow up etc)

Work involved inpreparation of application

Anticipatedoutcome?

Pros

Reliable, steadysource of income.Potentially a lot ofparticipants!

Possibly biggestsingleconstituency.Lots of smalldonations can addup!Generally,individuals havemost loyalty tolocal causes.

Opportunity toinform people ofwork while havingfun.

Can be high valuesource of incomefor discreteprojects.

Yourinstitution

Yourcommunity

Grant-makingbodies

“I congratulate THET on the production of such acomprehensive, yet user-friendly Manual, which will be aninvaluable resource for all those involved in health Links.A definitive guide to good practice, it will support thedevelopment of effective, dynamic links that really do makea difference to healthcare services in some of the poorestareas of the world.”Sally Venn, Lead for International Health,National Public Health Service forWales, UK

“Over the years our Link with Leicester has helped us tolook at new ways of doing things and has supported ourprofessional development. However I think this Manual willhelp us all to consider and understand what we need to doto make the impact of this work even greater. I lookforward to working through it with my colleagues.”HibrituMengiste,Head of Nurses,Ophthalmic Unit, Gondar, Ethiopia

"This Manual brings together many years of learningand best practice. It is an excellent resource, providingguidance for Links whether they are firmly established orjust getting off the ground. It will prove valuable for theRCP's own link with theWest African College ofPhysicians."Matthew Foster,Head of International Affairs,International Office , Royal College of Physicians, UK

“The success of a Link lies in setting the priorities correctlyi.e. within the existing National Health Policy and utilisingthe existing health architecture. Change happens slowly.When we started our link way back in the early 1990s, wedid not have any guidelines. This Manual will help all thoseinvolved in Links to learn from other peoples’ successes andmistakes making it harder to go wrong.”Agatha Nambuya, Senior Consultant Physician,Mulago Hospital, Kampala, Uganda

“This is an impressiveManual which brings together thepracticalities of running a Link. A vital piece of reading forall those engaged in Links.”Morag Reynolds, Public Health Development Lead for Primary Care/Health Links Co-ordinator, Sefton PCT, UK

the international health links manual

Documents

thelinks manual

copyright thet

different models of

short history of links

use ofthis manual

thet staff

thet andthet

uk organisation