Creating Sustainable Impact

Through Short-Term Volunteering in Asia

_____________________________________________

An Analysis of Singapore International Foundation’s

Health Capacity Building Projects in Indonesia, Vietnam
and Cambodia

A Report Commissioned by the Singapore International Foundation

By

Dr Emma Louise Jones

Independent Consultant, Singapore

Dr Caroline Brassard
Assistant Dean of Academic Affairs and Senior Lecturer
Lee Kuan Yew School of Public Policy
National University of Singapore

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 Table of Contents
Executive Summary ........................................................................................................... 6
Acronyms and Abbreviations ........................................................................................... 14
CHAPTER 1: Introduction ................................................................................................. 16
1.1 Background ........................................................................................................................... 16
1.2 Literature review on valuing volunteering .......................................................................... 17
1.3 Research focus: Evaluating SIF Specialist Team projects .................................................... 20
1.4 Report outline ...................................................................................................................... 21
CHAPTER 2: The SIF Specialist Team volunteer model ...................................................... 22
2.1 The aim of SIF Specialist Team projects .............................................................................. 22
2.2 Initiation of SIF Specialist Team projects............................................................................. 22
2.3 The structure of Specialist Team projects ........................................................................... 23
2.4 Volunteer roles ..................................................................................................................... 25
2.5 Host agency roles ................................................................................................................. 26
2.6 SIF roles................................................................................................................................. 26
2.7 Project management ............................................................................................................ 26
CHAPTER 3: Defining and evaluating ‘capacity development’ ........................................... 29
3.1 Defining ‘capacity development’ ......................................................................................... 29
3.2 The different levels of capacity ............................................................................................ 29
3.3 Organisational capacity ........................................................................................................ 30
3.4 Capacity development and its evaluation ........................................................................... 30
3.5 The appropriate scope for evaluations of capacity building .............................................. 31
3.6 Approach to evaluating SIF’s projects ................................................................................. 29
CHAPTER 4: Methodology ................................................................................................ 33
4.1 Key questions which framed the evaluation ....................................................................... 33
4.2 Sampling methodology ........................................................................................................ 34
4.3 Design and refinement of the research tools ...................................................................... 39
4.4 Design of the research process ............................................................................................ 41
4.5 Data collection oversight and quality assurance ................................................................ 39
4.6 Methodology for data analysis ............................................................................................ 44
4.7 Limitations ............................................................................................................................ 44
CHAPTER 5: Country contexts ......................................................................................... 46

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 5.1 Indonesia .............................................................................................................................. 47
5.2 Cambodia .............................................................................................................................. 48
5.3 Vietnam ................................................................................................................................ 50
CHAPTER 6: Outcomes for individual trainees .................................................................. 49
6.1 Individual capacity development: Hard skills...................................................................... 49
6.2 Sustainability in the use of new technical skills .................................................................. 59
6.3 Individual capacity development: Soft skills ....................................................................... 60
CHAPTER 7: Organisational capacity development ........................................................... 65
7.1 Internal systems and coherence .......................................................................................... 65
7.2 Internal organisation and action ......................................................................................... 70
7.3 External networks and recognition ..................................................................................... 69
7.4 The learning environment.................................................................................................... 75
7.5 Impacts on service delivery and outcomes for patients ..................................................... 81
7.6 Sustainability of organisational change .............................................................................. 84
7.7 Unexpected impacts of the SIF projects .............................................................................. 85
CHAPTER 8: Outcomes in the wider profession and sector ............................................... 86
8.1 Horizontal impacts ............................................................................................................... 86
8.2 Vertical impacts .................................................................................................................... 89
CHAPTER 9: Success factors and challenges for capacity development ............................. 94
9.1 Volunteer training methods................................................................................................. 94
9.2 Contextual factors within the host agency.......................................................................... 97
9.3 Project design and oversight by the SIF............................................................................. 104
CHAPTER 10: Social relationships and international understanding built through a
volunteer-driven development approach ....................................................................... 109
10.1 Building people-to-people ties .......................................................................................... 109
10.2 Perceptions of Singapore and Singaporean ...................................................................... 111
10.3 Building of trust and enduring relationships ..................................................................... 112
CHAPTER 11: Conclusions and recommendations ............................................................... 113
11.1 Key findings and recommendations .................................................................................. 114
11.2 The SIF Specialist Team model for short-term volunteering ............................................ 117
11.3 Suggestions for further research......................................................................................... 118
References .................................................................................................................... 119

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List of Tables
Table 1: Organisational Capacity – five core components..................................................................... 30
Table 2: Overview of Healthcare Projects.............................................................................................. 35
Table 3: Number of participants by research tools by country (excluding pre-testing) ........................ 36
Table 4: profile of the host agency staff that participated in the evaluation ........................................ 38
Table 5: Summary of development indicators by country..................................................................... 46
Table 6: Summary of heath financing indicators by country ................................................................. 46
Table 7: Summary of child and maternal health indicators by country ................................................ 46
Table 8: Modalities used for cascade training ....................................................................................... 77
Table 9: Cascade training facilitation ..................................................................................................... 80
Table 10: Trainers’ experiences of cascade training .............................................................................. 80
Table 11: Cascade training – estimated number trained....................................................................... 87
Table 12: Most useful training methods (Survey results n=90) ............................................................. 94
Table 13: Volunteer approaches to capacity development – success factors and challenges .............. 98
Table 14: Perceptions of Singapore and Singaporeans fostered through the SIF project ................... 112

List of Figures
Figure 1: SIF Specialist Team project cycle ............................................................................................ 28
Figure 2: The ‘most useful’ technical medical skills developed as a result of the SIF projects.............. 52
Figure 3: Changes in professional behaviour influenced by the SIF project .......................................... 60
Figure 4: Changes to internal coherence as a result of the SIF projects................................................ 66
Figure 5: Changes to external networks and recognition due to the SIF projects................................. 73
Figure 6: Changes to the learning environment as a result of the SIF projects ..................................... 75
Figure 7: Changes to service delivery and outcomes for patients after the SIF training ....................... 81
Figure 8: Changes to other organisations beyond the host agency ...................................................... 86
Figure 9: Changes at the national level .................................................................................................. 90

List of Boxes
Box 1: An example of an SIF Specialist Team project: The Traumatology project, Indonesia ............... 24
Box 2: Perceptions of cascade training .................................................................................................. 80

List of Annexes
Annexe 1: Evaluation Timeline ............................................................................................................ 122
Annexe 2: SIF Concept Note ................................................................................................................ 123
Annexe 3: Survey Questionnaire ......................................................................................................... 125
Annexe 4: Focus Group Discussion Questions ..................................................................................... 129
Annexe 5: In-Depth Interview Questions (Managers in Host Organisations) ...................................... 130
Annexe 6: In-Depth Interviews with SIF Volunteers ........................................................................... 132
Annexe 7: Consent Form ...................................................................................................................... 133

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Acknowledgements
This report was commissioned and financed entirely by the Singapore International
Foundation (SIF). At SIF, we sincerely wish to thank the following people for their unfailing
support throughout the research: Jean Tan, Margaret Thevarakom, Deeksha Vasundhra, Koh
Beng Hong, Lynn Goh, Joanne Lin, Melissa Jane Zehnder, Patricia Koop Miller, Jolene Chiang
and the SIF intern, Foo Zhi Wei.

We sincerely thank and acknowledge the participants in the research, from the: Saiful Anwar
Public Hospital, Malang, Indonesia; Health Polytechnic of Malang, Indonesia; Dr Soetomo
Hospital Surabaya, Indonesia; Lawang State Mental Hospital, Lawang, Indonesia; National
Paediatric Hospital, Phnom Penh, Cambodia; Cambodian Physical Therapy Association,
Cambodia; Caritas Centre for Child and Adolescent Mental Health, Takhmau, Kandal
Province, Cambodia; National Centre for Tuberculosis and Leprosy Control (CENAT), Phnom
Penh, Cambodia; National Cancer Hospital (K2 Branch), Hanoi, Vietnam; Vietnam National
Heart Institute, Hanoi, Vietnam; National ENT Hospital, Hanoi, Vietnam.

We also thank the SIF volunteers that participated in the research.

A special thank you also goes to all the research assistants without whose passion, this
research would not be successful. In Cambodia — Sok Leang and Chea Bunnary; in Indonesia
— Gunwan Tanuwidjaja, Andarita Rolalisasi and Intan Rahmawati; in Vietnam — Tuan Thanh
Nguyen and Phung Hanh Ngan; and in Singapore — Juairiyah Amir

Finally, we thank our families for their love, patience and unconditional support.

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 Executive Summary
Since the mid-1990s, the Singapore International Foundation (SIF) has developed and
implemented a ‘Specialist Team’ approach to volunteer projects. This model involves a skill-
sharing partnership between a multi-disciplinary team of specialist volunteers and an
organisation in a developing country (the host agency), who implement a targeted
programme of capacity building. Each volunteer input is one to two weeks in duration, and
these are made within a long-term relationship of more than two years. This model of short-
term volunteering enables professionals with limited available time, but plenty of expertise
and passion, to be part of an international volunteering effort.

SIF Specialist Team projects have two main aims:

 Upgrading the skills of overseas professionals to improve professional practice and

the quality of basic services in the country;
 Training of Trainers (TOT): Creation of a core team of trainers in the overseas
institution or sector, to lead professional training for long-term improvements in the
quality of services in the country.

Specialist Team projects aim to empower local partners so that they can become catalysts
for long-term positive change in their professional community. To support the process of
capacity development, the SIF also supports training attachments in Singapore and resource
donations as part of the Specialist Team projects. The projects are designed to emphasise
self-reliance through a focus on institutional and sectoral capacity development. The SIF also
aims to build social relationships and understanding through its volunteer projects (see
Chapter 2).

The SIF prioritises projects that focus on themes that are particularly important in the local
context or to achievement of the millennium development goals (MDGs). It also prioritises
specialist areas in which Singapore has particularly strong skills to share.

Having carried out Specialist Team capacity-building projects for nearly 20 years, the SIF
commissioned this evaluation to assess the long-term impacts of its projects from the
perspectives of host agency staff. The study also aims to analyse the success factors and
challenges of this model of short-term volunteering, to enhance the SIF’s volunteer
engagement and overseas capacity-building projects.

Design of the evaluation

The research is based on a sample of 12 health sector projects in three countries –

Cambodia, Vietnam and Indonesia (see Chapter 4). To enable analysis of sustainability, each
of these projects had concluded between two and ten years ago. The analysis reviews the
outcomes of the SIF projects at four levels:

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1. Capacity development outcomes for individual trainees
2. Organisational capacity development outcomes for the host agency
3. Impacts in the wider profession and sector
4. Building of cultural understanding and international relationships.

For each project, 15-19 host agency staff were interviewed, alongside one SIF volunteer. In
total 213 people were interviewed, including 197 host agency staff. Three types of research
tools were developed for the research with the host organisations, to enable data
triangulation:

 The survey questionnaire was designed for host agency staff who participated in the SIF
Specialist Team project. The questions focused largely on the individual level of capacity
development and the impacts of these changes on service provision, as well as the TOT
component of the projects.

 The focus group discussion (FGD) with host agency staff explored four themes: Analysis
of the training approaches used by the SIF volunteers; technical skills gained and their
contribution to organisational capacity development; behavioural change and new
organisational processes; and social relationships and international understanding built
through the projects.

 The in-depth interview with host agency managers who oversaw the SIF project focused
on organisational change and contributions to change in the wider sector, as well as
international relationships built through the projects.

The evaluation findings of the SIF Specialist Team projects are summarised in the sections
below.

Skills development outcomes for individual trainees (see Chapter 6)

Technical skills: There is large variation in the technical focus of the host agencies included in
this evaluation, yet some common themes can be discerned as an entry point to success
factors and challenges. In all of the SIF projects, the volunteer teams helped to upgrade and
update the technical knowledge of host agency staff. About 43% of trainees perceive that
their enhanced theoretical knowledge is one of the most useful outcomes of the SIF projects,
largely because it propels their knowledge forward and underpins the new techniques they
were taught. Most of the SIF volunteer teams also taught new specialist diagnosis skills,
which improved trainees’ ability to assess patients accurately and identify appropriate
treatment. Five of the SIF projects in this evaluation supported capacity building in hospital
departments that provide life-saving services. In each of these host agencies, trainees

7
explained that the use of new techniques, alongside stronger teamwork and more coherent
systems, has created faster and more accurate treatment. This has helped to enhance staff
confidence and in some cases, reduced mortality rates in the hospital.

There have been some challenges, however. About 39% of respondents felt that one of the
most useful technical skills they gained from the SIF project is the use of specialist
equipment. Yet a lack of equipment availability is one of the most common problems noted,
particularly in relation to the sustained use of the new technical skills developed as part of
the SIF project. There were also some challenges in the difficulty-level of the training ‒ 23%
of trainees felt that some of the training was too advanced.

Sustainability in the use of new technical skills: This is enhanced by a holistic approach to
training for most of the projects, from diagnosis to treatment and monitoring. Sustainability
is also significantly enhanced by the development of formal protocols and guidelines which
help to institutionalise the new techniques, thereby providing more authority for their use.
However, in a few of the host agencies, the use of the new technical skills has not been
formalised by their integration into protocols. Another key challenge for sustainability has
been a lack of resources within the host agencies, leading to the lack of availability of both
equipment and supplies.

Soft skills gained by individual trainees: Staff from all 12 projects expressed quite significant
changes in professional behaviour, and this was perceived to be among the most important
outcomes of the SIF projects. Across the host agencies, a key outcome of the SIF projects
has been enhanced communication with patients (74% of respondents) and a new ability to
successfully counsel patients into accepting lifesaving or life-changing treatment. Many of
the SIF projects have also influenced better communication and collaboration within staff
teams (63% of respondents). In nine projects (56% of respondents), trainees perceive that
the SIF volunteers helped to enhance staff motivation and professionalism. Some 41% of
respondents also perceive that the training led to a more patient-centred approach.

Organisational capacity development (see Chapter 7)

The analysis of organisational capacity development focused on five types of capacities:

Internal systems and coherence within the host organisation: 75% of the projects
influenced the introduction of new patient management and documentation systems, more
systematic patient assessment and monitoring and more coherent team structures and roles.
Five of the projects saw better coordination with other departments through new systems
for information sharing and joint surgery. However, there was limited organisational change
in the projects which involved individual trainees from a wide set of different organisations.

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Influence on internal organisation and action in the host organisations: 41% of host agency
managers felt that the SIF project had not impacted on leadership or management skills. In
most cases, they felt that the volunteers had focused on building the capacity of the staff
rather than the managers. Yet around half of the host agency managers felt that the projects
had some impact on leadership and planning. This was particularly in relation to increased
awareness of the need for forward planning, and development of clearer staff
responsibilities and systems within the organisation. In some host agencies, respondents felt
that leadership has been enhanced because trainees who participated in the SIF project have
been promoted into managerial positions.

External networks and recognition from stakeholders: Respondents from six of the host
agencies explained that they now have greater recognition from patients, due to their
enhanced skills and more successful outcomes. A commonly mentioned indicator of this
recognition is that more patients use their services, rather than other available public or
private service providers. The trainees of four of the host agencies (all in Indonesia)
explained that they are now newly recognised as the national centre in their field. Three of
the host agencies have also contributed to national technical guidelines on their specialist
area. Many agencies expanded their national and international networks.

Influences on the learning environment: In most host agencies, the SIF projects have had
some impact on staffs’ motivation to learn new skills to teach and research and managerial
commitment to internal training. Cascade training of the SIF teaching modules within the
host agencies is one example of managerial commitment to staff development. Ten of the
host agencies have facilitated fairly substantial and regular internal trainings, based on (or
including) the SIF volunteer teaching modules. Across projects, the largest number of
cascade trainings took place within the host agency, yet 40% of respondents also trained
people from external organisations.

Service delivery and outcomes for patients: Eight of the projects contributed to the
development of new types of health services that were not previously available. Moreover,
all of the projects influenced some level of more successful treatment and outcomes for
patients. For example, respondents from seven host agencies noted that the SIF projects
have led to faster patient recovery times. Five of the projects have led to faster emergency
response times, which were most often related to more coherent team systems and team
communications. This has contributed to a reduction in patient mortality rates within four of
the partner organisations.

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Outcomes in the wider profession and sector (see Chapter 8)

Horizontal impacts relate to influences on individuals and organisations beyond the host
agency. All but one of the host agencies provided training for staff of other organisations, to
share the knowledge and skills they had gained as a result of the SIF project. In particular, in
the eight host agencies that are teaching hospitals (in Indonesia and Vietnam), skill-sharing
with other organisations has been achieved partly through the existing system of learning
placements for staff of other organisations and students. Many of the respondents explained
that they have used and shared the skills and knowledge in the other organisations and
contexts in which they work, including private clinics and voluntary work. A process of skill-
sharing beyond the host agency has also been achieved by the movement of trainees.

Vertical impacts are influences at a higher level, on the sector at large or at the national
level. One important influence over the wider sector is national policy. Five of the projects
influenced policy change or new guidelines at the regional or national level. In this regard, a
significant factor contributing to changes in government legislation and guidelines is the level
of influence of the host agency in government domains. Three of the host agencies (all in
Indonesia) have developed new formal tertiary education courses as a result of the SIF
project and four additional host agencies have integrated the knowledge gained from the SIF
volunteers into national level training programmes.

Success factors and challenges for capacity development (see Chapter 9)

Success factors and challenges are analysed at three levels:

Volunteer approaches to capacity development: From the perspective of host agency staff,
some of the most useful approaches to training were provision of a strong theoretical
grounding in lectures, supported by interactive teaching methods and practical guidance in
work with patients. Early provision of printed training materials, ‘quick reference charts’ and
manuals helps to deepen and sustain learning. Behavioural change, such as enhanced
professionalism and motivation, is largely catalysed by working alongside the volunteers and
observing their working style and interaction with patients. An overarching finding on
behavioural change is that host agency staff became more motivated, confident and
dedicated as the projects progressed and they began to see more successful results in their
work with patients. The greatest challenge of the skill-sharing process is the
language/translations used in the training sessions. Another large challenge is the need to
adapt the techniques used in Singapore for use with the equipment and supplies available in
the local contexts. While the SIF promotes the use of locally appropriate approaches, a few
of the volunteer teams used equipment and supplies in the trainings that are not readily
available in the host agencies.

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Host agency and contextual factors: The host agencies’ access to resources is a key factor
which has hindered progress in some host agencies, and enabled progress in others. Across
the three countries, a lack of finances has been a challenge for the purchase of equipment
and supplies required for the sustained use of some of the techniques taught by the SIF
volunteers. In some of the host agencies, understaffing (and low staff remuneration) were
also a challenge for the training process, and for the use of new techniques that require
more time spent with each patient.

The commitment of host agency staff and managers is another crucial factor in the success
of projects. A change in the mindset and motivation of host agency staff was perceived by
many volunteers as one of the largest outcomes of the projects and a factor that
underpinned other changes.

In most of the host agencies, the managers have also institutionalised the new systems and
techniques through the development of new protocols and guidelines. This has been critical
to the sustainability of organisational change. Additionally, where the host agency has
gained recognition for its work, for example by national government or international
agencies, this enhances its access to funding and its potential to influence government
programmes and policy.

Project design and oversight: Some project design factors have contributed to capacity
change and some have created challenges. One key factor is the number and type of
organisations which were partners in the SIF project. In projects which focused on one
hospital department (sometimes alongside a higher education institution), the volunteers
were able to take a holistic approach to capacity development, and to see where skills,
systems and behavioural issues needed to be worked on together. This model of Specialist
Team project also enabled the volunteers to develop relationships with both the staff and
managers of the host agency. In contrast, the two projects that engaged with a dispersed set
of organisations (with just a few trainees from each) achieved skills transfer but less
organisational changes.

Another factor related to the choice of organisational partners is the inclusion of a teaching
hospital or a higher education institution. This was a particularly successful approach to
project design because it provides a structure for cascade teaching, which has helped to
sustain and broaden the skill-sharing impacts of the projects. However, projects that
included more than one organisational partner were complex to manage, both for the
overseas organisations, the volunteers and the SIF.

The TOT approach is, overall, a successful design component of the Specialist Team projects.
Nearly all host agencies went on to provide substantial programmes of cascade training,
both within and outside the host agencies. There are some challenges however. These

11
include the difficulties of facilitating cascade training for organisations that do not have an
existing teaching structure, and in some cases, a lack of skills and confidence to teach others.

Another significant success factor in many of the projects in this evaluation was the demand-
driven nature of many projects, and the way that the SIF engages the host agency
management in their design and oversight. This has helped to promote host agency
ownership of the projects, and has fostered significant commitment among most of the host
agency managers.

Social relationships and international understanding built (see Chapter 10)

Around half of host agency managers have kept in touch with one or two of the volunteers,
particularly the lead volunteer. The relationships vary: some are about both friendship and
work; while some are just about work or just for friendship. In most cases, the staff of host
agencies explained that only their superiors have kept in touch with the SIF volunteers. For
many host agency staff, a challenge of maintaining contact has been the need to
communicate in English.

In general, the experiences of Singapore by those who visited the country as a result of the
SIF training were positive, with participants stating cleanliness, modernity and beauty as key
characteristics of the country. In terms of understanding of Singaporeans, on a professional
level, trainees mentioned the level of commitment, flexibility and responsiveness as
essential aspects. On a personal level, the perception of Singaporeans was mixed. Though
most shared the view that Singaporeans were disciplined and respectful, a few respondents
perceived overconfidence and a sense of superiority as negative traits of some Singaporeans.

Key findings and recommendations arising from the evaluation (see Chapter 11)

 Projects which focus on one service delivery organisation (e.g. one hospital department)
promote a holistic approach to capacity development and organisational change.
Projects which engage a wide set of organisations (with just a few trainees from each)
achieve skills transfer but less organisational change.
 The inclusion of a teaching hospital or a higher education institution provides a structure
for cascade training, which helps to sustain and broaden the skill-sharing impacts of the
projects. Where a formal teaching course is developed as part of the SIF project, this
promotes impact on the wider profession and sector.
 Training approaches used by SIF volunteers: Interactive teaching methods promote
learning; practical guidance with patients helps host agency staff understand how new
techniques can be used in practice; printed reference materials help to deepen and
sustain learning.
 The greatest challenge of the skill-sharing process is the language/translations used in
the training sessions. It is recommended that training materials be sent to the host

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 agency well in advance of the training sessions to allow for good quality translation, and
to develop a bilingual glossary of technical terms.
 SIF volunteers should ensure that the training is relevant, particularly with regard to the
equipment and supplies available within the host agency. They should also ensure that
their training is pitched at the right level, and provides enough depth.
 It is recommended that the SIF volunteers work with the host agency to promote
development of new protocols and guidelines that institutionalise the new techniques
and systems, in order to promote organisational change and sustainability.
 The TOT programme should more clearly identify ‘trainers’; volunteers should provide
training on ‘how to teach’ and build trainers’ confidence to teach others; TOT would be
improved by the provision of comprehensive training materials for host agency staff to
use when they facilitate cascade training.

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Acronyms and Abbreviations
ACPP Advanced Certificate in Physiotherapy Practice

CPR Cardiopulmonary Resuscitation

ECDPM European Centre for Development Policy Management

ECG Electrocardiogram

ENT Ear Nose and Throat

ETAT Emergency Triage Assessment and Treatment

FGD Focus Group Discussion

GDP Gross Domestic Product

HIV/AIDS Human Immunodeficiency Virus infection / Acquired Immunodeficiency Syndrome

ICU Intensive Care Unit

INTRAC International NGO Training and Research Centre

IO Intra-osseous Infusion

ISO International Standards Organisation

MA Master of Arts

MDG Millennium Development Goals

NGO Non-Governmental Organisation

PDCA Plan Do Control Action

Rp Rupiah

RTCCD Research and Training Centre for Community Development

SIF Singapore International Foundation

SIV Singapore International Volunteer

SOP Standard Operating Procedure

TOT Training of Trainers

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development

VND Viet Nam Dong

WHO World Health Organisation

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15
 CHAPTER 1: Introduction
1.1 Background

International volunteerism has taken on a particular form in contemporary

Singapore, where the highly competitive professional environment does not
always enable people to take extended periods of leave in order to volunteer.
Responding to this situation, in the mid-1990s the Singapore International
Foundation (SIF) developed its ‘Specialist Team’ approach to volunteer projects.
This model involves a skill-sharing partnership between a multi-disciplinary team
of specialist volunteers and an organisation in a developing country, who
implements a targeted capacity building programme. As busy professionals, the
volunteers travel for short periods of 1-2 weeks, 2-3 times a year, within a long-
term relationship of two to five years. This model of short-term volunteering
enables professionals with limited available time, but plenty of expertise and
passion, to be part of an international volunteering effort.
1.1.1 SIF Specialist Team projects have two main aims:
 Upgrading the skills of overseas professionals to improve professional practice
and the quality of basic services in the country;
 Training of Trainers (TOT): Creation of a core team of trainers in the overseas
institution or sector, to lead professional training for long term improvements
in the quality of services in the country.
1.1.2 Specialist Team projects aim to empower local partners so that they can become
catalysts for long-term positive change in their professional community. To
support the process of capacity development, the SIF also supports training
attachments in Singapore and resource donations as part of the Specialist Team
projects.
1.1.3 Leveraging on Singapore’s expertise, the SIF focuses its skill-sharing volunteer
projects on particular sectors — healthcare, education, social services, livelihoods
and governance. SIF Specialist Team volunteers do not work directly with local
communities. The volunteer teams work with the staff of the host agency (e.g. a
hospital or school) to design and implement an intensive programme of capacity
building that responds to identified needs. The projects are designed to
emphasise self-reliance through a focus on institutional and sectoral capacity
development. The SIF also aims to promote the building of social relationships
and international understanding through its volunteer projects.
1.1.4 This report presents the findings of an evaluation of SIF Specialist Team projects.
The aim of the evaluation was to analyse the long-term impacts of the projects,
and associated success factors and challenges, from the perspectives of host
agency staff. The research is based on a sample of 12 health sector projects in

16
 three countries — Cambodia, Vietnam and Indonesia. Facilitated by independent
consultants, the evaluation was commissioned by the SIF to support learning and
improvement.
1.1.5 The research also contributes to the emerging body of writing on the ‘value of
volunteering’ and its potential to help tackle development challenges. It
highlights the impact that volunteers make towards achieving developmental
goals while bringing their own set of unique contributions to the host community-
trust developed through professional relationships helps build stronger
relationships between people of different countries, thereby contributing to
international understanding.

1.2 Literature review on valuing volunteering

1.2.1 Some critics contend that international volunteering programmes can be

volunteer-centred, neo-colonial and ineffective in tackling development issues
(Suchdev, 2007; Deveroux, 2008). The problems identified include a lack of
ownership by host organisations, the dominance of a hierachical expert paradigm
and ambigious accountabilities (Pratt, 2002). Other writers argue that the
outcomes for host organisations depends on the particular design, content and
relevance of the volunteering activity, as well as the capacities of the volunteers
and the sending and host organisations (Lough et al, 2011; Sherraden et al, 2008;
Repair the World 2010). This point usefully highlights the importance of
reviewing particular projects, models and relationships as a basis for
understanding the potential of different forms of volunteering. Some recent
writing has identified factors of volunteer projects which may influence their
effectiveness. In this section, we briefly discuss the factors which are relevant to
analysis of SIF Specialist Team projects, using examples of healthcare volunteering
where relevant.
1.2.2 The duration of volunteer placements has been identified as a factor that
influences their effectiveness. While short-term volunteers are valued for the
skills they share and their potential to link host agencies to external resources
(Lough, 2012), their work is often challenged by limited understanding of the local
organisation and culture, and weak relationships and trust (Deveroux, 2008;
Sherraden et al, 2008). This in turn can affect the development outcomes of
projects. In contrast, long-term volunteer placements help to enable the building
of relationships and understanding, and the completion of concrete initiatives
(Lough et al, 2011). Due to this, long term volunteers may hold greater potential
to achieve developmental outcomes, such as technical skills transfer (White and
Cliffe, 2000). However, in his comparison of long- and short-term placements in
Kenya, Lough (2012) found that the long-term volunteers in his sample tended to

17
 be slightly older and more experienced than some of the short-term volunteers
(such as youth placements). This highlights how other factors coincide with the
duration of volunteer service.
1.2.3 Sherraden et al (2011) also note that consecutive volunteer placements may
potentially overcome some of the challenges of short-term volunteering,
although she does not elaborate on how. This point is particularly relevant to SIF
Specialist Team projects, which support consecutive short-term volunteer
placements within a long-term commitment of several years, tied together by a
targeted programme of capacity building.
1.2.4 Another factor in the design of projects is the individual or group nature of
placements. Individual placements may promote greater cultural immersion and
understanding (Sherraden et al 2008). As highlighted above, such local
understanding may help to enable development outcomes within host
organisations and communities. On the other hand, group placements often
make more significant tangible contributions due to their economies of scale
(Ibid).
1.2.5 The specific objectives of the volunteer project also influences the outcomes for
host communities and organisations. While some volunteer initiatives focus
largely on cross-cultural understanding, other projects focus largely on skill-
sharing or service delivery and give secondary emphasis to cross-cultural learning
(Sherraden et al 2008). The aim of projects shapes the outcomes. Many medical
volunteer projects focus on the provision of direct services in communities, and
tend to pay limited attention to building the capacity of local medical staff
(DeCamp 2011). In their research on the outcomes of direct service medical
volunteer projects, Green et al (2009) found that community members had
become reliant on the free services provided by medical volunteers, and used
these instead of government services. This highlights how the medical volunteers
in this project worked in isolation from the local medical system, which affected
the sustainability of outcomes. Some recent writing on medical volunteerism has
developed ethical guidelines, which include the need to integrate with existing
health structures and build local capacity through ‘training of trainers’ (Wilson et
al 2012, DeCamp 2011, Suchdev et al 2007).
1.2.6 Volunteer attributes such as skills, personality and motivation, are another factor
that affects the outcomes of volunteer placements on host organisations.
Relevant specialised skills are particularly important in placements that are
designed to provide technical assistance. Lough’s study in Kenya found that
highly skilled volunteers, on both long- and short-term placements, were valued
by host organisations for the skills that they transfer and ideas that they bring
(Lough 2012). Yet, even when volunteers have the required technical skills, their

18
 effectiveness is strongly affected by their ability to work in the local language
(Lough et al 2011). The motivation to volunteer can also affect the process and
outcomes of volunteering. For example, DeCamp (2011) notes that short-term
international medical volunteering has become a common component of training
for healthcare professionals in the USA. Wilson et al (2012) note that medical
volunteers on such programmes may prioritise personal learning experiences
over the parallel aim of community development.
1.2.7 The institutional capacity of both sending and host organisations has large
influence over the design and implementation of projects. Among the key
challenges for sending organisations are funding and resources, as well as
evaluation and research (Brassard, Sherraden and Lough, 2010). This research
attempts to fill this gap by focusing on the seldom researched impact of short
term volunteerism.
1.2.8 Both sending and hosting organisations can affect volunteers’ capabilities through
orientation, language training and supervision (Sherraden et al 2008). The
effectiveness of projects is also shaped by the capacity of host organisations to
work with and support volunteers (Repair the World 2010), which can take up
considerable time and resources (Lough et al 2011). Project outcomes are also
affected by the relationship between the host and sending organisations,
including their mutual understanding of goals and expectations, and clear and
effective communications (Repair the World 2010).
1.2.9 Volunteer projects also need to be accountable to communities and host
organisations, and respond to their needs and priorities (Deveroux 2008, Pratt
2002) through shared decision-making processes (Repair the World 2010). This
promotes a partnership model of volunteering, which encourages mutual learning
and skill-sharing. Where volunteer sending organisations (or their funders)
promote a particular agenda, accountability to communities becomes secondary.
This can negatively affect the project outcomes, as well as local motivation and
acceptance (VSO 2002, cited in Lough et al 2008).
1.2.10 This review of literature has highlighted several factors that may influence the
outcomes of volunteer projects. Yet, “although short-term international
volunteers are well intentioned, we know relatively little about their actual
effects on host communities and organisations — particularly from the
perspectives of host organisation staff” (Lough et al 2011: 121, Green et al 2009).
This evaluation of SIF Specialist Team projects aims to plug this gap and
contribute to the emerging research on the value of volunteering, by analysing
the developmental outcomes of particular volunteer projects from the
perspective of host agency staff.

19
 1.3 Research focus: Evaluating SIF Specialist Team projects

1.3.1 This evaluation of SIF Specialist Team projects focuses on four key themes and
‘levels of change’, which relate to the SIF’s objectives in these volunteer capacity-
building projects. These four themes, outlined below, were analysed from the
perspective of host agency staff:

1. Capacity development outcomes for individual trainees: Technical skills,

behavioural change.
2. Capacity development outcomes for the host agency: Were capacity changes
institutionalised within host agencies? Had these improved the services for
the community?
3. Impacts in the wider profession and sector: Were there higher level changes
beyond the host agency?
4. Building of social relationships and international understanding: Had the
projects promoted social relationships and international understanding
through the building of cultural appreciation and trust?

For each theme, the evaluation aimed to discern some of the key success factors
and challenges.
1.3.2 The evaluation was undertaken in 2012, and is based on a sample of 12 health
care projects in three countries (Cambodia, Vietnam and Indonesia). While the
SIF had initially asked for an evaluation of both health and education projects, it
was agreed that a focus on one sector would enable a more detailed comparative
analysis. Each of the projects in the sample were completed between two and
ten years ago (between 2003 and 2010), to enable analysis of sustainability,
progress and challenges after the project was closed.
1.3.3 In the three focal countries, the SIF has facilitated 13 Specialist Team health care
projects which were closed between 2003 and 2010. The evaluation included all
of the health care projects that matched the research criteria. Twelve projects
were included in the main evaluation, and two additional projects (including one
that was completed in 2011) were used to pre-test and refine the research
questions.
1.3.4 For each of the 12 projects, between 15-19 host agency staff were interviewed —
through focus group discussions, in-depth interviews, and questionnaire-style
interviews. These interviews were complemented by interviews with one
volunteer from each project. In total, 213 people were interviewed (see Table
3). The interviews with host agency staff were facilitated in the local language,
by nationals of that country who are not related to the SIF or the host agency.

20
 This approach was taken to promote free and open discussion, including analysis
of challenges.

1.4 Report outline

1.4.1 Following this introductory chapter, the SIF Specialist Team volunteer project
model is outlined (Chapter 2). Then, the report provides a definition of
‘organisational capacity’ and ‘capacity building’ (Chapter 3) and an explanation of
the research methodology (Chapter 4). This is followed by a brief discussion of
the health sector contexts in the three focal countries (Chapter 5). The findings of
the evaluation are discussed over the next four chapters: outcomes for individual
trainees (Chapter 6); organisational capacity development (Chapter 7); outcomes
on the wider professional community and sector (Chapter 8); success factors and
challenges for capacity development (Chapter 9); and social relationships and
international understanding built through the projects (Chapter 10). The report
concludes with a discussion of the key findings and suggestions for further
research (Chapter 11).

21
 CHAPTER 2: The SIF Specialist Team volunteer model
This chapter outlines the main elements of SIF Specialist Team projects, including: the aim of
the projects; how they are initiated, designed and managed; and the role of the volunteers,
the SIF and the overseas partners.

2.1 The aim of SIF Specialist Team projects

2.1.1 SIF Specialist Team projects have two main aims:

 Upgrading the skills of overseas professionals to improve professional practice
and the quality of basic services in the country;
 Training of Trainers (TOT): Creation of a core team of trainers in the overseas
institution or sector to lead professional training for long-term improvements
in the quality of services in the country.
2.1.2 To support capacity development, the SIF also supports training attachments in
Singapore and resource donations as part of the Specialist Team projects.
2.1.3 The overarching objective of Specialist Team projects is to empower local
partners so that they can become catalysts for long-term positive change in their
professional community. The projects aim to promote self-reliance and
sustainable capacity building within the host agency, through an emphasis on
institutional development and training of trainers. The projects also aim to
impact on the wider sector, by working with teaching institutions and relevant
government bodies; and by encouraging the host agencies to provide cascade
training to other organisations. All SIF projects aim to promote the building of
cultural understanding, social relationships and international understanding,
including mutual learning, trust and friendships.

2.2 Initiation of SIF Specialist Team projects

2.2.1 Specialist Team projects are initiated either by SIF or by the host agency. Among
the health sector projects that were the focus of this research, half were initiated
by the host agency and were therefore demand driven. In some cases, a senior
staff member of the host agency met with a Singaporean medical specialist at an
international conference; and they together developed the idea of skill-sharing
and contacted the SIF for support. In other cases, the host agency made contact
with a professional medical association to request for capacity building, and the
SIF was contacted by this association. In making funding decisions on health
sector projects, the SIF prioritises:
1. Medical themes that are particularly important in the local context (such as
physiotherapy in post-conflict Cambodia) or to achievement of the MDGs
(such as paediatric medicine and tuberculosis);

22
 2. Specialist areas in which Singapore has particularly strong skills to share;
3. Projects that have strong stakeholder support.

2.3 The structure of Specialist Team projects

2.3.1 SIF Specialist Team projects engage highly skilled professionals from Singapore,
such as doctors, nurses, teachers and engineers. The volunteers work in
multidisciplinary teams and are partnered with a host agency in a developing
country to share skills and build capacity on their specialist area. Most projects
are two to five years in duration, although some have several phases and thus last
for up to ten years.
2.3.2 Specialist Team projects have four key design elements:
1. All Specialist Team projects include direct technical skill-sharing, through both
theoretical and practical training. Many projects also support soft skills
development, such as enhanced communication with patients.
2. All Specialist Team projects include TOT. A ‘core team’ of host agency staff
are identified as ‘trainers’, who work closely with the volunteers to develop
their skills to impart cascade training in the wider organisation and sector.
3. Most of the projects include guidance on aspects of organisational capacity
development. This varies from guidance on developing new departments,
organisational systems, team structures and protocols; to less substantial
changes such as the development of new forms for patient assessment.
4. Most of the projects also involve a training attachment in Singapore, when a
small number of host agency staff are hosted by the volunteers (in their
homes and organisations) for one to four weeks. The training attachments
take place towards the end of the project. The aim is to reinforce the capacity
building by providing an opportunity for host agency staff to see the skills and
systems being applied in the Singapore context.

23
Box 1: An example of an SIF Specialist Team project: The Traumatology project, Indonesia

The Traumatology Project, Indonesia

The host agencies for this project were the Faculty of Medicine at Brawijaya University and the
Department of Emergency Medicine at Saiful Anwar Hospital, both in Malang. The SIF also worked
closely with the Provincial Health Department. The volunteers were a team of doctors and nurses that
specialise in different types of emergency medicine, who work at the Singapore General Hospital and
Nanyang Polytechnic in Singapore.

The volunteer team was led by a professor who was a senior staff member of the Singapore General
Hospital Emergency Department. He visited the host agencies for one week at the start of the project,
to support a capacity and needs assessment and to design a targeted multi-year programme of skill-
sharing and TOT. The lead volunteer identified and managed a team of 96 volunteers, over the seven
years of the project (1997-2003). Some of the volunteers participated in many of the training visits,
while others joined the team for just one or two trainings that were relevant to their specialisation.

The project involved seventeen training visits, each of which were one to two weeks in duration.
Each training visit had a targeted technical focus (such as operating theatre management, triage,
cardiac emergency, etc) and were designed as a TOT programme. The volunteers shared skills through
a combination of classroom-style teaching, hands-on support in the wards and surgery, and helping to
develop new guidelines and team systems. The volunteers also provided technical support to
development of a new regional ambulance service and a specialist Master’s degree course in
emergency medicine. Towards the end of the project, ten staff of the host agencies visited Singapore
General Hospital for a two-week training attachment to reinforce the capacity building. The
outcomes of the project are discussed later in this report.

24
 2.4 Volunteer roles

2.4.1 Over the duration of a Specialist Team project, a large number of volunteers
participate. For example, the Palliative Care project in Vietnam involved 40
volunteers over 12 visits (1995-8), while the Emergency nursing project in
Indonesia involved 17 volunteers over seven visits (2007-9). The volunteers
provide short-term capacity building inputs (1-2 weeks at a time, 2-3 times a year)
within a long-term relationship of more than two years. Some of the volunteers
participate in the entire project, while others engage in just the trainings that
relate to their specialisation. Since the Specialist Team model enables volunteers
to make short inputs, the SIF is able to attract very high-calibre specialists.
2.4.2 Each project has a lead volunteer. Many projects also have a deputy lead
volunteer, whose skills complement the lead volunteer (for example, a paediatric
emergency doctor may be paired with a paediatric emergency nurse or university
lecturer).
2.4.3 The roles of the lead volunteers are as follows:
1. During the process of project design, the lead volunteers work with the host
agency to facilitate a ‘feasibility study’ and needs assessment, and propose a
targeted programme of capacity building and that responds to these needs;
2. Technical leadership for the project – design and oversight of the skill-sharing
and TOT programme;
3. Building close relationships with host agency management and staff;
4. Identification and management of the team of specialist volunteers;
5. The lead volunteers are responsible for preparing ‘project progress reports’
after each training visit and at the mid-term and end of the project. In these
reports, the volunteers can recommend adjustments to the focus and scope
of the skill-sharing programme.

25
2.4.4 Most projects involve a partnership with one or two Singaporean organisations
(such as a paediatric hospital, or specialist university department), from which
many of the volunteers are sourced. This creates opportunities for professional
enrichment for their staff. Because many of the volunteer team members work
together in Singapore, they are able to draw on their common understanding of
effective systems, as well as existing team spirit. In some cases, the volunteers
draw on their organisations to facilitate equipment donations to the host
agencies. The volunteers' organisations in Singapore are also the setting where
host agency staff visit for training attachments.

2.5 Host agency roles

2.5.1 Within the host agencies, a manager is identified who is responsible for the
project and oversees the capacity building programme in partnership with the
lead volunteer and SIF country manager.
2.5.2 A core team of host agency staff are also identified as trainers. This core team
works closely with the volunteers to build their skills to facilitate cascade training.
In some projects, this core team co-facilitates training sessions alongside the
volunteers. This co-facilitation is intended to enhance local ownership of the
projects, the adaption of skills to the local context and the teaching capacities of
local staff. Between volunteer visits, and after the SIF project is completed, it is
intended that this core team provide cascade training for their colleagues and
staff of other organisations.

2.6 SIF roles

2.6.1 Within the SIF, each project is managed by an SIF ‘Country Manager’, who
manages the project, the partners and the volunteers. The SIF Country Manager
is responsible for:
1. Project management: Oversight on project initiation and design, progress
reporting, coordination of dates and participants for training workshops, and
attendance at most volunteer training visits;
2. Management of partner relationships: Managing relationships with the host
agency and volunteers;
3. Support and orientation: Supporting the volunteers while they are overseas
(insurance, safety, travel and lodging, etc.).

2.7 Project management

2.7.1 The SIF formalises its relationship with the host agency through a Letter of
Agreement (LOA) which sets out expectations on both sides. In most cases, the
host agency agrees to provide particular forms of support to the project, such as

26
 helping to facilitate visas for volunteers and organising training space and
participants.
2.7.2 When required, the SIF also develops an LOA with the organisation(s) in
Singapore from which the volunteers are sourced. Some of the larger
organisations which regularly partner with the SIF are able to support the projects
by allowing some of the volunteering to be undertaken on a paid leave
arrangement, or by permitting unpaid leave.
2.7.3 SIF Specialist Team projects have a set of required planning and monitoring
reports:
 A feasibility study is facilitated by the lead volunteer in collaboration with the
host agency, which identifies capacity-building needs and highlights factors
that may support the project (such as managerial commitment and
opportunities for cascade training).
 If the project is considered feasible, a project proposal is prepared which
details the objectives of the project, the proposed programme of capacity
building and intended outcomes.
 After each training visit, the volunteer team prepares a post-training report
(and mid-project review) which reflects on progress, challenges and next
steps. These reports include feedback from the host agency staff and
managers. Based on the recommendations in these reports, projects may
take new directions in response to emerging needs and challenges.
 At the end of the project, the volunteers prepare an end of project review
which takes stock of the project, its outcomes and challenges along the way.
 One year after the projects are closed, the volunteers also undertake a project
audit which reviews the progress of new techniques and cascade training
implemented. The audit visit also provides an opportunity for the volunteers
and host agency staff to meet, to reinforce their friendships and share ideas.
2.7.4 Over 2011-12, the SIF has developed a more comprehensive project development
and monitoring framework. Following this framework, recent project proposals
include an analysis of the baseline capacity and detailed outcome indicators.

27
Figure 1: SIF Specialist Team project cycle
1. Identification of potential project
After a series of discussions with the SIF, the host agency submits a
Request Form for a Specialist Team project. The SIF then makes
make an initial assessment of the viability of the project, and
approaches a Singapore partner to request for a volunteer(s) to
conduct a feasibility study.
2. Feasibility Study
The Feasibility Study is facilitated by a volunteer(s) with relevant
specialist skills, who agrees in principle to be the volunteer team
leader if the project is implemented. The volunteers visit the host
agency for up to one week, to conduct a capacity assessment and
needs analysis.
3. Project Proposal
If the project is deemed feasible; the host agency, volunteers and
SIF work together to prepare a detailed Project Proposal. This
outlines the need for the project, existing capacity, the aim and
objectives, and a proposed skill-sharing programme. They also
confirm the manager responsible within the host agency, the
volunteer team leader and participating Singapore organisations
from which volunteers will be sourced. More recent Project
Proposals include a capacity baseline and monitoring indicators. A
suitable funder is sought, if necessary, and partnership terms
established.
28
. and baseline indicators,
5. Project Review and Audit
Each project undergoes a Mid-Project Review. This provides feedback from the
host agency and volunteers; and an assessment of whether training is on track to
achieve the objectives of the project. Adjustments may be made to the training
programme and possibly to the project objectives.
The End-of-Project Review is facilitated by the volunteers and host agency, and
provides an assessment of technical project outcomes. The Project Audit is
facilitated by the volunteers and SIF one year after the project is completed. The
Audit evaluates the sustainability of skills transferred. This visit is also used to
discuss next steps and the possibility of a follow-up project.
4. Project implementation
SIF Specialist Team projects are implemented broadly in line with the agreed
project proposal. Yet the SIF provides much needed flexibility. This allows the
projects to develop at the required pace, and to be refocused in response to
emerging needs.
Such changes are proposed in the post-training report, which is prepared by the
volunteer team after each training visit. These reports include feedback from the
host agency trainees and managers, and interim updates on project progress (and
monitoring indicators where relevant).
 CHAPTER 3: Defining and evaluating ‘capacity development’
This chapter briefly explains the concept of ‘capacity’ and approaches to evaluating capacity
development.

3.1 Defining ‘capacity development’

3.1.1 There are many different definitions of capacity and capacity building. OECD
defines capacity as “the ability of people, organisations and society as a whole to
manage their affairs successfully” (OECD 2006, cited in INTRAC 2010:3).
“Capacity development can be seen as a deliberate process whereby individuals
or organisations strengthen and maintain capacity over time” (INTRAC 2010: 3).
Capacity development is an internal process that involves the staff of
organisations taking responsibility for change, often including changes in
relationships and norms (ibid).
3.1.2 The SIF has a flexible approach to capacity development, which enables the
volunteers to develop a programme of skill-sharing that responds to the
particular needs of the partner organisation. The main focus of Specialist Team
projects is to build technical skills among the staff of the host organisation, and
to promote cascade training in the wider sector through the ‘training of trainers’
model (SIF 2011: 3). Yet many projects also support forms of organisational
capacity development (such as enhanced work processes or team systems); and
most projects also promote soft-skills development (such as enhanced
communication with patients).

3.2 The different levels of capacity

3.2.1 Capacity can be defined at different levels – individual, organisational, sectoral

and societal (SIF 2011: 3). Drawing on Morgan (2006), these levels of capacity
can be summarised as follows:

Individual capacity Organisational Sectoral capacity Societal capacity

capacity
 Hard skills Wider contextual Cultural, economic
(technical Systems and and governance and social contexts
medical skills processes within processes, such as: which affect the
and associated the organisation, sector, such as:
such as:  Healthcare
theory)
policy &  Community
 Soft skills &
professional  Staffing & management demand for
team systems  Availability of services
behaviour
(communica-  Planning & financial &  Ability to
tion, teamwork, leadership human access and pay
mindset,  Work resources for healthcare
motivation) processes &  Training for services
policies healthcare
woers

29
3.2.2 Each of these levels of capacity interacts and affects each other (Land 2000,
Morgan 2006). For example, individual staff members may have good soft and
hard skills, but they need effective management, systems and resources to
achieve their goals. Organisational capacity is likewise influenced not only by
internal systems, but also by the capacities of individual staff and external factors
such as the policy framework and the economic context.

3.3 Organisational capacity

3.3.1 Some recent international development workshops have developed a concept of

organisational capacity which usefully identifies five core components (Engel et
al 2006, Zinke 2006, Pasveer 2012). Table 1 summarises these five core
components (as explained by Engel 2006: 4-5) and provides some illustrative
examples which relate to the health sector.
Table 1: Organisational capacity – five core components
Component of organisational
Positive examples (from the health sector)
capacity
 Coherent team structure and staff roles
1. Capacities to achieve  Strong team work and communications
internal coherence  Effective internal systems and processes
 Comprehensive & clear guidelines that govern operations

 Inspiring and effective leadership

2. Capacities to self-organise
 Effective planning and action taken on decisions
and act
 Effective management of resources (human and financial)
 Staff are well managed and stimulated to perform


 Good relations with relevant external stakeholders

3. Capacities to relate with
 Perceived credibility and legitimacy
external stakeholders
 Mobilisation of required financial and human resources
 Knowledge and experience is shared with external partners


4. Capacities to learn and  Opportunities to learn

adapt  Willingness to absorb new ideas and adapt
 Willingness to teach share skills and knowledge with peers

 Effective provision of healthcare services

5. Capacities to achieve
 Substantive healthcare outcomes
development results
 Sustainability of service delivery improvements


This evaluation of SIF Specialist Team Health projects utilises this understanding of organisational
capacity as a framework for analysis.

3.4 Capacity development and its evaluation

3.4.1 Capacity development can be understood as an internal process through which

individuals and organisations create, strengthen and maintain their capacity over

30
 time (INTRAC 2010: 3). Capacity building is often a process of external support
which aims to catalyse a process of capacity development (ibid: 4). Evaluations
of capacity building therefore involve analysis of both capacity development
outcomes and how these changes were supported (or hindered) by external
support.
3.4.2 INTRAC (2010: 7) notes several challenges in evaluating capacity-building
support, many of which were encountered in this evaluation of SIF Specialist
Team projects:
 It is difficult to isolate one input – such as SIF Specialist Team projects – from
other forms of external support (ibid).
 There can be a lengthy time gap between capacity-building interventions and
desired end results.
 Results may be stretched between several different organisations, and there
are practical difficulties in coordinating M&E across these organisations (this
problem was encountered in the evaluation of several SIF Specialist Team
projects which involved ‘residents’ – doctors in training – who were not
permanent staff of the host agency).
 Capacity is not a linear process – organisations are in constant processes of
flux and change, influenced by internal momentum as well as the external
context. It is therefore difficult to attribute change to specific interventions.

3.5 The appropriate scope for evaluations of capacity building

3.5.1 Several of the challenges outlined by INTRAC (above) refer to the problem of
attribution: To what extent can a change (such as better services) be realistically
linked to particular input (such as a training workshop)? Responding to this
problem, Flynn (2010) explains that evaluations should focus on the ‘sphere of
influence’ of the organisation. She usefully takes the volunteer sending
organisation (VSO) as an example:
3.5.2 VSOs’ implementation strategy is for volunteers to work directly with partner
organisations to build their capacity to effect change in the community. Their
direct sphere of influence is therefore building the capacity of their partner
organisations. This should be the primary focus of their impact assessment.
There is a concomitant responsibility to explore changes that occur at the
community level, but this is the responsibility of their partner organisations. VSO
will be able to provide illustrations of change at this level, but not assess it (Flynn
2010: 8).
3.5.3 Flynn also notes that even when evaluations focus on the appropriate sphere of
influence, it is difficult to confidently claim ownership of the change. This is
because each change is affected by a myriad of factors, both within the partner
organisation and the wider context. For this reason, many development

31
 organisations now explore and document their ‘contribution to change’, and
focus on illustrating change rather than trying to ‘measure it’ (Flynn 2010: 9).

3.6 Approach to evaluating SIF’s projects

3.6.1 The approach to evaluation of the SIF Specialist Team projects was informed by
the frameworks outlined in this chapter. The evaluation focuses largely on the
direct sphere of influence of SIF Specialist Team projects: individual capacity (soft
and hard skills) and organisational capacity (focusing on the five components
outlined above). At a secondary level, the evaluation also explores outcomes in
the wider sector, and social relationships and understanding built through the
projects. Rather than attempting to measure change, this evaluation report
provides illustrations of the SIF projects’ contributions to change. Where
possible, the analysis compares these changes across projects to help identify
success factors and challenges.

32
 CHAPTER 4: Methodology
This chapter explains the research methodology used for the evaluation, including the key
questions that framed the analysis, the sampling methodology and the research methods
that were used.

Implemented over eight months in 2012, the evaluation was designed and implemented by
two independent consultants (the ‘lead researchers’). They were supported by seven
independent research assistants in the three focal countries, who facilitated the research
with host agency staff in their local language. The SIF engaged independent researchers to
undertake the research to promote an objective assessment of its projects, with the aim of
supporting internal learning and improvement. The SIF provided the lead researchers with a
concept note (see Annexe 2) which outlined the objectives of the evaluation, key questions
and the countries on which to focus (Vietnam, Cambodia and Indonesia).

The overarching aim of the evaluation was to analyse the outcomes of SIF Specialist Team
projects, as a particular model for short-term volunteering; and to identify the success
factors and challenges of this model through comparative analysis of different projects.

The SIF proposed a focus on projects that had been completed between two and ten years
ago (2002-10). This time-frame was identified to enable evaluation of sustainability,
independent progress and challenges since the project closed. It was considered that the
evaluation could not review sustainability in very recent projects, while it would be difficult
to facilitate reflection on very old projects. The SIF also asked that the evaluation focus on
the perspectives of host agency staff be complemented by interviews with relevant
volunteers and SIF country managers. The timeline of the evaluation is shown in Annexe 1.

4.1 Key questions which framed the evaluation

4.1.1 The evaluation focused on four key levels of change within the sphere of
influence of SIF Specialist Team projects. At each level, the evaluation aimed to
discern success factors and challenges.
1. Individual capacity development
What kinds of sustainable technical skills and behavioural change have
resulted from the projects?
2. Organisational capacity development (focusing on the five components)
What forms of organisational capacity have been built, and have these been
sustained and developed since the projects were completed? From the
perspective of the host agency, what is the change in quality of service
provided to the community because of trainees’ enhanced skills?

33
 3. Outcomes in the wider profession and sector
What are the impacts of the SIF project on the wider professional community
or sector (beyond the host agency)?
4. Social relationships and international understanding built
What relationships were formed through the SIF projects and have they been
sustained? What are the perceptions of Singapore and Singaporeans that
have been formed as a result of partnership on SIF projects?

4.2 Sampling methodology

Project sampling

4.2.1 The following criteria were used in the selection of projects for the evaluation:
 Health sector Specialist Team projects: to enable comparative analysis of
projects that vary greatly, the lead researchers decided to focus on projects
within one sector (healthcare).
 Projects that were completed between two and ten years ago: to enable
analysis of sustainability.
 Clusters of projects in one geographical area in each country due to budget
and time constraints: Clusters of four health sector projects were identified in
Hanoi (Vietnam), Malang/Surabaya (Indonesia) and Phnom Penh (Cambodia).
4.2.2 Overall, 13 projects were identified which matched the research criteria. The
most recent project and one additional suitable project were identified by the
lead researchers for pre-testing of the research tools. The remaining 12 projects
became the focus of the evaluation.
4.2.3 Some of the host agencies in this evaluation provide services that save lives,
while others provide services that improve quality of life. There is also a
difference in the number and type of organisations included in each SIF project
(see Table 2).
4.2.4 In addition to these structural differences in the project design, there were quite
large differences in the duration and dates of the projects:
 Variation in project duration: Two years (Speech therapy, 2008-09) to seven
years (Traumatology 1997-2003 and Otolaryngology 2003-9)
 Variation in the dates of the project: most recent (Paediatric ICU, 2008-11)
and oldest (Traumatology, 1997-2003.
4.2.5 These differences provided useful comparisons for the evaluation. Yet, as
discussed in section 4.6, the differences also slant the evaluation data. For
example, host agencies in which the projects were completed long ago have had
more time to make changes and implement cascade training.

34
Table 2: Overview of healthcare projects

Focus Areas Host Agency partners

Duration Department
of project Healthcare Healthcare of a public Network
Number of
& number services to teaching Department of
Country Project volunteers
of that save improve hospital and of a public service
volunteer lives quality of 1-2 Higher hospital delivery
visits life Education NGOs
Institutions
Indonesia Traumatology 8 years 96
(1997-2003) 17 visits

Emergency 3 years 17
Nursing 7 visits
(2007-09)
Occupational 3 years 25
Dermatology 9 visits
(2005-07)
Reconstructive 3 years 31
Surgery 8 visits
(2007-09)
Vietnam Palliative Care 2 years 43
(2005-07) 12 visits
Psychosocial 2 years 21
Skills in 6 visits
Palliative Care
(2008-10)
Otolaryngology 7 years 23
(ENT)(2003-09) 8 visits
Cardiac Nursing 2 years 24
(2008-10) 9 visits
Cambodia Paediatric 3 years 36
Emergency 8 visits
(2004-7)
Paediatric 2 years 28
Intensive Care 8 visits
(2008-10)
Physiotherapy 5 years 51
(2006-10) 18 visits
Speech 2 years 14
Therapy 5 visits
(2008-9)

35
 Sampling of individual respondents

4.2.6 For each project, the evaluation aimed to interview 15-19 host agency staff:
 Three host agency staff at managerial level (‘managers’) who helped to
design and manage the SIF Specialist Team project.
 14-16 host agency staff (‘trainees’) that participated in the SIF capacity-
building programme
4.2.7 The respondents were identified through purposeful sampling. The manager of
each host agency was emailed to ask for a full list of host agency staff that had
engaged in the SIF skill-sharing programme and were available to participate in
the evaluation. The researchers then identified respondents based on their role
within the host organisation (e.g. ensuring an even balance between doctors and
nurses) and gender. For the two projects that involved many NGOs, the
researches selected respondents from a cross-section of NGOs, again with
attention to a balance in professional roles and gender
4.2.8 A grand total of 213 people were interviewed, including 197 host agency staff.
The breakdown of respondents by research tool is indicated in Table 3.
Table 3: Number of participants by research tools by country (Excluding pre-testing)

Cambodia Indonesia Vietnam Singapore

Background 13 SIF volunteers
- - -
interviews 3 country managers
Managerial
12 12 12 -
Interviews
Focus Group
19 24 17 -
Discussions
Survey
34 32 32 -
Questionnaire
Total 67 68 62 16
Grand total 213

4.2.9 The SIF initially contacted the host agencies, and relevant government
departments, to explain the aims of the evaluation and to invite them to
participate. After SIF had gained their consent, the lead researchers then
worked with the host agencies to agree on the dates, participants and process
for the evaluation.
4.2.10 Challenges: One of the host agencies (for the Otolaryngology project) did not
have 19 staff members who could participate in the evaluation. This was
because a large number of the trainees had been ‘Residents’ (doctors in training)
and were no longer working at the host agency. For this project, only 10 staff
participated in the evaluation: three managers were interviewed and eight
trainees participated in the questionnaire (the FGD was not undertaken). Table

36
 4 provides the detailed profiles of all the participants of the evaluations based
on their gender, age group and occupation.
4.2.11 In most projects, some of the identified respondents were not in the end
available for interview. This was partly due to holiday leave and illness, but also
because some staff were attending to medical emergencies at the time of the
FGD, or were on a rural placement.

37
Table 4: Profile of the host agency staff that participated in the evaluation

Gender Age of respondent Professional role of respondent

20- 30- 40- 50+ Medical Educator
Male Female 30 40 50 Doctor Nurse Manager technician (medical) Other
Indonesia Projects
Emergency Nursing 5 12 1 2 12 2 0 14 2 0 9 0
Occupational Dermatology 13 4 3 6 2 6 16 1 1 0 8 0
Reconstructive Surgery 7 10 2 8 4 3 16 1 1 1 8 2
Traumatology 12 5 0 7 6 4 7 9 2 1 6 0
Sub TOTAL 37 31 6 23 24 15 39 25 6 2 31 2
Cambodia Projects
Paediatric Emergency 13 4 0 6 6 5 8 8 9 3 10 0
Paediatric Intensive Care 7 8 4 7 3 1 5 10 7 1 4 0
Physiotherapy 10 7 3 11 3 0 0 0 8 5 5 14
Speech Therapy 7 11 7 7 2 2 2 2 6 3 7 2
Sub TOTAL 37 30 14 31 14 8 15 20 30 12 26 16
Vietnam Projects
Cardiac Nursing 5 12 5 11 1 0 0 16 2 2 1 0
Otolaryngology (ENT) 9 2 1 8 1 1 11 0 3 0 4 0
Palliative Care 5 12 1 8 7 1 5 12 4 1 4 0
Psychosocial skills in Palliative 4 13 3 7 6 1 8 9 3 0 0 0
care
Sub TOTAL 23 39 10 34 15 3 24 37 12 3 9 0
Grand TOTAL 97 100 30 88 53 26 78 81 48 17 66 17
(Note: respondents could identify more than one professional role, e.g. doctor and manager)

38
 4.3 Design and refinement of the research tools

4.3.1 The design of the research tools took account of the evaluation objectives
outlined in the SIF Concept Note and insights from the literature on capacity
building and its evaluation. To inform the design of the research questions, the
consultants first read all available reports relating to the focal projects (feasibility
studies, project proposals, post-training, mid-project and Audit reports). One
challenge was that not all reports were available, particularly for the older
projects. This review highlighted some significant differences between the
projects. Some of the structural differences between the projects were used as
factors for comparative analysis (such as projects that focused on one hospital
department compared to projects that included many NGOs). Yet some of the
differences between the projects presented a challenge for design of the
research questions.
4.3.2 Challenges in the design of the research questions: The technical focus of the
host agencies varies greatly: from otolaryngology and reconstructive surgery in
specialist hospital departments, to speech therapy with children in community
contexts. Since the evaluation aimed to provide comparative analysis of the
projects, the research had to be designed to provide one set of questions that
were relevant to all projects. The research themes and questions therefore had
to be designed and worded in a way that would have meaning to a wide range of
respondents ‒ specialist surgeons, therapists, palliative care nurses and so on.
For example, questions on organisational change needed to be relevant to NGOs
and hospital departments, and questions on technical skills needed to be
relevant to psychiatrists and surgeons. For this reason, the questions were
necessarily broad, open-ended and designed to enable different interpretations.
This enabled respondents to discuss the changes and challenges that were most
significant to them. Yet, at the same time, the wide variety of responses was a
challenge for data analysis (see Chapter 4).
4.3.3 The research tools: For the research with host agency staff, three different
research tools were developed: A survey questionnaire, a Focus Group
Discussion (FGD) and an in-depth interview with managers. Each research tool
was designed to explore particular themes, with either managers or staff of the
host agency. To enable triangulation, each question was incorporated into more
than one research tool.
4.3.4 The survey questionnaire for host agency staff who participated in the capacity-
building programme (trainees). The survey questions (see Annexe 3) focused
largely on the individual level of capacity development (individual skills and
behavioural change) and the impacts of these changes on service provision. The
questionnaire also included sections on organisational change, the ‘training of
39
 trainers’ element of the projects, and contributions to change in the wider
sector. While some of the questions were closed-end (enabling quantitative
analysis), most of them were open-ended and asked for personal stories of
change and challenges.
4.3.5 The FGD with host agency staff (trainees). The FGD explored four themes (see
Annexe 4):
Analysis of the training approaches used by the SIF volunteers; technical skills
gained through the projects, and their contribution to organisational capacity
development; behavioural change and new organisational processes resulting
from the projects; relationships and understandings of Singapore built through
the projects.
4.3.6 An in-depth interview for SIF volunteers was also developed for background
purposes. This was facilitated with the lead volunteer (and /or deputy lead
volunteer) for each project. The questions (see Annexe 6) explored the
volunteer’s perspective on the successes and challenges of the project, the
teaching approaches they used, and international relationships developed
through the projects.
4.3.7 Each research tool, and all personal data and consent forms, were translated into
the three local languages (Khmer, Indonesian and Vietnamese) by SIF volunteers
based in Singapore. The translations were then reviewed and revised by the
research assistants.
4.3.8 Pre-testing and refining the research tools: The first draft of the research tools
were reviewed by the SIF. They were then reviewed in an FGD with SIF Specialist
Team volunteers who had worked on health sector projects in countries other
than Indonesia, Cambodia and Vietnam. Some key points raised in the FGD
were: (a) simplify many of the questions; for example, adjust questions asking for
the ‘most significant change’ to alternatively ask for ‘important changes that
have occurred’. This was because it was felt that it is difficult to identify the
‘most significant change’; (b) avoid asking too many questions on organisational
change to nurses (because nurses are often disempowered and not aware of why
systems have changed). This led to a first revision of the research tools.
4.3.9 To ensure that the research questions were appropriate, answerable and would
provide useful data; the research tools were pre-tested in two host agencies (the
Respiratory Medicine project in Cambodia and the Geriatric Psychiatry project in
Indonesia). It is important to note that the data from the pre-test is not included
in the analysis in this report. 11 host agency staff participated in each pre-test
(two managerial interviews, three questionnaires and six participants in the
FGD). The pre-testing was also used as a practical route to training the research

40
 assistants on the research tools and process, including facilitation and
documentation skills.
4.3.10 The pre-test of the research tools was facilitated by the research assistants in the
local language, supported by the lead researchers. At the end of each pre-test,
the lead researchers facilitated discussion with some host agency staff (and later
the research assistants) on how the tools could be improved. The pre-test led to
a second refinement of the tools. This included numerous changes to the
wording of questions, deletion of questions that didn’t work well, and the
addition of some questions (e.g. did the SIF projects impact on poorer patients?).

4.4 Design of the research process

4.4.1 All of the research with host agency staff was facilitated in the local language.
Most of the research took place at the host agencies. For the two projects in
Cambodia that included many NGOs (which are geographically dispersed across
the country), many of the respondents kindly travelled to the host agencies in
Phnom Penh and Takmau. The research assistants travelled to the NGO clinics in
rural areas to facilitate the remaining interviews.
4.4.2 Focus Group Discussion participants were selected to include doctors or nurses
(not both) since the staff hierarchies may have inhibited free discussion and
contributions from less senior staff. The FGDs were facilitated by one of the
research assistants, who noted contributions on a white-board, while the other
research assistant documented the discussion in detail. The research assistants
used locally appropriate facilitation methods, and paid attention to enabling
contributions from all participants. There were some differences in how the
FGDs were facilitated in the three countries. For example, in Indonesia questions
on perceptions of Singapore and relationships with volunteers were noted on
cards by each participant and not verbally discussed. This was because, in
Indonesia, the research assistants perceived open discussion of “another culture
and its people” as inappropriate.
4.4.3 Questionnaires were facilitated face-to-face by the research assistants, who
documented responses on the questionnaire form. The questionnaire was
facilitated face-to-face to enable verbal responses (which was perceived as easier
for the respondents), and to ensure that the questions were understood and the
answers were well documented.
4.4.4 In-depth interviews: The questions for the in-depth interview were emailed in
advance to host agency managers. This was to allow time for them to consider
their answers and to gather data on the numbers of people that participated in
cascade training, and any available secondary data related to the SIF projects.

41
4.4.5 Documentation: All interviews and FGDs were recorded through note-taking and
audio-recorders. Interviews with host agency staff were initially documented in
the local language, and then translated into English.
4.4.6 Secondary data collection: Where the host agency had secondary data related to
the outcomes of the SIF project (e.g. a report on cascade training or service
delivery statistics) this was collected by the research assistants. Very few of the
host agencies were able to provide secondary data, but where it was provided,
the information has been integrated into this report.

4.5 Data collection oversight and quality assurance

4.5.1 To promote the quality and comparability of the data, the lead researchers
developed a detailed training kit for the research assistants. The training kit
included an explanation of the evaluation objectives and questions, as well as
instructions on the research process (including consent, confidentiality and
profile forms for each respondent). The training kit also provided background
information on each SIF Specialist Team project.
4.5.2 Using the training kit, the lead researchers imparted two-day training for the
research assistants (one training session was facilitated in each country). In
Cambodia and Indonesia, the training was followed by the pre-test of the
research tools in a host agency. This provided a practical way to reinforce the
training, as well as to identify challenges and required changes to the proposed
research process and questions. Additionally, translation of the research tools
into the local language was double-checked by volunteers so as to minimise any
misinterpretation and ensure clarity of questions.
4.5.3 The lead researchers oversaw the data collection phase of the research from
Singapore (through Skype and email) and through one visit to each country. At
the end of the data collection phase, the lead researchers facilitated a three-day
meeting with the research assistants, to review, discuss and clarify all of the data
and translations.
4.5.4 Confidentiality, consent and appreciation: Each respondent in the host agencies
signed a consent form (see Annexe 7) which explained the confidential nature of
their interview and confirmed that their names would not be associated with
their comments. Each respondent was also provided with an information sheet
on the evaluation and its aims. The research assistants asked permission from
each respondent to record the interview using a digital recorder – none of the
respondents objected.
4.5.5 Each respondent was given an SIF corporate gift as a token of appreciation for
their participation in the evaluation.

42
4.5.6 Challenges in the data collection process: Various challenges arose in the process
of data collection. One challenge, noted above, was less than anticipated
numbers of respondents being available. Other challenges included:
 While all of the respondents remembered their work with the SIF volunteers,
for the older projects it was difficult for participants to recall the details (for
example, to list the different training approaches used). This challenge was
greatest in the individual questionnaires. The group dialogue in the FGDs
helped trainees to remember more details.
 While some of the host agency staff participated in the entire SIF project,
some staff participated in only some of the training sessions. This was for
various reasons – from human resource challenges in the host agency to staff
relocations. Host agency staff that participated in only some of the trainings
were unable to fully answer some of the questions.
 Although respondents highlighted many changes that resulted from the SIF
projects, in many cases the respondents found it difficult to identify the
process of change (to explain the link between the capacity-building inputs
and its outcomes).
 Some of the questions were misinterpreted by the respondents. This was
partly influenced by the less direct nature of the languages of the evaluation
(compared to English).
 In one host agency, there was a misunderstanding over the SIF’s role in the
skill-sharing project (some of the host agency staff believed that the project
had been led and funded by the Singaporean lead volunteer and that the SIF
had only been involved in funding the attachment in Singapore). This
misunderstanding led to host agency staff finding difficulty in answering
questions about the SIF volunteers. The misunderstanding was cleared up by
the lead volunteer who has developed very close personal relations with the
host agency staff and with the SIF. The research then continued successfully.
 In another host agency, one of the managers felt that the evaluation
duplicated the project audit that had been completed several years
previously. This manager did participate in the evaluation, but asked that his
comment be formally recorded. The SIF wrote to this manager to explain the
purpose of the evaluation in more detail, and to thank him for his support
and time taken.
• In the evaluation of the Occupational Dermatology project in Indonesia, many
of the questionnaire respondents participated in the cascade training led by
the host agency staff, but not in the trainings facilitated by the SIF volunteers.
The host agency’s inclusion of these staff members in the evaluation
highlights one success of the project, i.e. that cascade training took place and
is understood as integral to the SIF project. Yet these staff were unable to
43
 answer many of the questions, which asked about the trainings facilitated by
the SIF volunteers. This issue was not communicated to the lead researchers
until after the evaluation with that host agency had been completed. For this
reason, the data analysis in this report does not include the questionnaire
responses for the occupational dermatology project.

4.6 Methodology for data analysis

4.6.1 Most of the questions asked in this evaluation were open ended and invited
respondents to give stories to illustrate changes and challenges. This approach
generated a large variety of responses and some very rich and illuminating data.
Qualitative data analysis aims to highlight and explain key themes,
commonalities and comparative differences. This analysis was achieved through
two main methods.
4.6.2 For open-ended questions, NVIVO (software for qualitative data analysis) was
used to identify common themes and trends in the data. Firstly, the data was
coded based on the key themes of the research and emerging trends were
summarised into tables and then synthesised. Secondly, an ‘open query’ method
was used to identify other recurrent themes (such as suggestions for future
trainings).
4.6.3 For closed-ended questions in the survey questionnaire, the data was inputted
into excel and analysed descriptively. Similarly, the information on the profile of
all respondents (focus groups, interviews and survey) was compiled into excel
spreadsheet and summarised into tables and graphs.
4.6.4 Some of the qualitative data in this report has also been presented visually, in
bar charts. The bar charts which compare the twelve projects help to highlight
which host agencies ‘achieved particular type of change’ as a result of the SIF
project. These achievements, and their link to the SIF project, are the
perceptions of host agency staff. As noted above, different responses were
coded and their frequency was counted. Since open-ended questions allow a
wide variety of potential responses, and the SIF projects focused on many
different themes over the years, the respondents highlighted quite different
aspects of change in their interviews. For this reason, in the bar charts on
organisational change in this report, an organisation is deemed to have achieved
a type of change if it was highlighted by at least three trainees and verified by the
FGD or at least one managerial interview (or verified by secondary data).

4.7 Limitations

4.7.1 One of the key limitations of the data is with respect to the comparability of the
SIF Specialist Team projects included in the evaluation, due to several factors.
Firstly, there are large differences in the technical focus of the host agencies,
which shape quite different capacity-building objectives. Some of the SIF
44
 projects supported the development of new specialisations within the host
agencies (such as in the Reconstructive Surgery project in Indonesia), or a new
department (such as the Paediatric ICU project in Cambodia) while other projects
focused on improving existing systems for patient management and work
processes. Consequently, there are challenges in comparing the outcomes of
projects which had quite different contexts and objectives. For example, the
respondents for the two projects which focused on improving surgery techniques
did not highlight significant changes to work processes because this was not an
identified need or aim of these projects (rather than this being a ‘weak element’
of the projects).
4.7.2 Secondly, the different country contexts also influenced the process and
outcomes of the SIF projects. As we highlight in the next chapter, the host
agencies have different challenges which are affected by the country context.
This includes limited finances, which influences the availability of supplies,
equipment and human resources, as well as low remuneration which affects staff
morale. The socio-economic context of the country, which influences the ability
of patients to access and pay for services, was also highlighted by some
respondents as a negative influence over the projects outcomes. Some aspects
of the country contexts had a positive influence over the outcomes of the
projects ‒ such as government support for cascade training.
4.7.3 Thirdly, given that the data was collected by three separate teams trained
individually in country, there were some differences in the methods used to
prompt respondents for particular questions. The use of prompts or follow-up
questions at times led the interviews to focus on a particular issue in some
depth, while other interviewers remained more generic in their questioning. In
addition, the translation of the research tools as well as the transcription and
translation of the responses were done by different volunteers and research
assistants in country, and the quality of output varied.
4.7.4 Another large limitation to the data analysis is ‘attribution’ of changes to the SIF
project. A large variety of factors beyond the SIF project influenced the
outcomes, including the ongoing work and initiatives of host agency staff, their
respective governments and other donors. This evaluation reports the changes
which host agency staff perceive the SIF project contributed to, in some way,
without claiming that the outcomes were a direct outcome of the projects. This
fits with the SIF’s perception of host agencies as the agents of change, and SIF
volunteers as catalysts for change.

45
 CHAPTER 5: Country contexts
The chapter provides background information on the development context and health
sector in the three focal countries: Cambodia, Indonesia and Vietnam. Where possible,
information is also provided on the specialist themes of the focal projects.

Table 5 to Table 7 provide some comparative numerical data on the three countries, such as
GDP and health sector financing. As the data illustrates, Cambodia is less developed than
Indonesia and Vietnam on many indicators including literacy, infant mortality, life
expectancy and health spending per capita. Indonesia has a larger GDP and urban
population than the other two countries. While Vietnam has a larger number of hospital
beds and physicians per capita and significantly lower maternal mortality. Influenced partly
by limited government budgets, an important similarity of the three countries is the large
private health care sector and the large amount of ‘out-of-pocket’ spending on health care
(health care costs which are paid by citizens rather than by government).

Table 5: Summary of development indicators by country

Development Indicators Indonesia Cambodia Vietnam

GDP (US Dollars, Billions) 2012 928.27* 14.20* 135.41*
GDP per Capita (US dollars) 2011 3,508.61* 1,374.01* 851.53*
Urban population (% of total) 53.7 22.8 28.8
Life expectancy at birth 69 63 75
% of population living on less than $1.25 a day 18.06 (2010) 22.75 (2008) 16.85 (2008)
Literacy rate, adult total (% of age 15+) 92.19 (2008) 77.59 (2008) 92.78 (2009)
Literacy rate, adult female (% of females age 15+) 89.10 (2008) 70.86 (2008) 90.50 (2009)
Source: All data is from the World Bank website (www.worldbank.org); apart from data indicated with * which
is from the IMF website (www.imf.org)

Table 6: Summary of heath financing indicators by country

Health Sector Financing Indonesia Cambodia Vietnam

Health expenditure per capita (current US$) 76.89 45.19 82.87
Health expenditure, public (% of government expenditure) 7.75 10.48 7.79
Health expenditure, private (% of total health expenditure) 50.92 62.77 62.16
Health expenditure, public (% of total health expenditure) 49.08 37.23 37.84
Hospital beds (per 1,000 people) 0.6 (2010) 0.84 (2010) 3.1 (2009)
Physicians (per 1,000 people) 0.29 (2007) 0.23 (2010) 1.22 (2008)
Out-of-pocket health expenditures (% of health spending) 75.13 64.35 60.03
Source: All data from the World Bank website (www.worldbank.org)

Table 7: Summary of child and maternal health indicators by country

Child and Maternal Health Indonesia Cambodia Vietnam

Under 5 mortality rate (deaths per 1000) 35 51 23
Infant mortality rate (under 1) (deaths per 1000) 27 43 19
Maternal mortality ratio (per 100,000 live births) 240 290 56
Source: All data from UNICEF website, 2010 statistics (http://www.unicef.org/infobycountry)
46
 5.1 Indonesia

5.1.1 Indonesia is a large country of 18,307 islands, with a population of nearly 249
million as of mid-2012. As an industrialising country with oil resources, Indonesia
has a higher GDP per capita than Cambodia and Vietnam (Table 5). Yet the
country has large income disparities and poverty problems, alongside significant
corruption which affects resources available for the provision of public services.
The large part of the Indonesian public sector was decentralised in 2001. This
affected the health sector, which is now largely the responsibility of regional
governments (WHO website, Country Fact Sheet).
5.1.2 The majority of Indonesians do not have access to affordable healthcare, with
access being most limited in rural areas and smaller islands (ibid). Two-thirds of
all doctors in Indonesia are based in Java, with 30% of these working in Jakarta.
The health system is generally understaffed (ibid). There is a deficiency in
required skills and low productivity (ibid), as well as outdated equipment (IRIN 26
June 2012). This affects the quality, efficiency and equity of health care provision.
Access to health care services is financed largely by out-of-pocket payments.
5.1.3 The Indonesian government increased health sector funding by 10% in 2011
(Jakarta Post 11 May 2011). This increase was partly to fund the health
insurance scheme for the poor (Jamkesmus), which was developed in 2008 to
enhance poor people’s access to basic health services (IRIN 26 June 2012). The
wider plan of the Indonesian government is to put in place a system of universal
social health coverage by 2014, to make basic hospital medical services available
to all, nationwide. The government also has policies to encourage the relocation
of doctors to rural areas, including a proposed salary incentive (Jakarta Post 11
May 2011).
5.1.4 Emergency medical care: Indonesia has a relatively high number of natural
disasters (volcanic eruptions, floods, landslides, etc.), road accidents and
violence; as well as the daily emergencies seen worldwide. Statistics for 2003
(Pitt and Pusponegoro 2005) highlight that trauma is the most common cause of
death among the 15-24 age-group and second most common in the 25-34 age
group, with 70% of trauma cases resulting from traffic accidents.1 The same
report notes that a large number of people die outside of hospital (92%), due
partly to a lack of pre-hospital care (such as ambulance services and police
trained in emergency first aid) as well as limited community knowledge on basic
first aid. This context was the background for two SIF Specialist Team projects
(Traumatology and Emergency Nursing) in the leading public hospital in Malang –
a small city in Surabaya Province of Java, Indonesia.

1
Infectious disease and coronary heart disease are the most common overall in Indonesia (Pitt and
Pusponegoro 2005).
47
5.1.5 Occupational dermatology: Indonesia has a large industrial sector and has
become a centre for particularly hazardous manufacturing processes (such as
tanneries and cigarettes). One report on occupational dermatology in Indonesia
(Febrianna et al 2012) explains that manufacturing processes involve the use of
harsh chemicals, which are often used in poorly ventilated areas and with no
provision of personal protective equipment to workers. The report also notes
that there is a limited legal framework to protect workers. While factories are
required to provide health insurance to their staff, in reality this is only provided
to a few higher-level workers in most factories. As a result, there is a high
incidence of occupational skin diseases, many of which go unreported and
untreated. Workers with an occupational skin disease often lose their jobs, or
are advised to resign by their doctor (ibid). This context was the background for
the SIF Specialist Team project on Occupational Dermatology in Malang,
Surabaya Province of Java, Indonesia.

5.2 Cambodia

5.2.1 Cambodia is one of the poorest countries in Asia, with a population of around
eight million people. Many aspects of the contemporary country context were
shaped by the Khmer Rouge regime (1975-78), during which public services and
infrastructure were destroyed and more than three million people are estimated
to have died or fled the country. By 1978, “the entire health system was
destroyed – equipment, supplies and personnel, along with major infrastructure,
power, water and sanitation. Only 45 medical doctors survived, and of those 20
left the country” (McGrew 2010). The periods of political and social instability
over the last 20 years have left a trail of injuries, deaths, and mine-infested lands
(USAID 2011).
5.2.2 Since 1979, the government of Cambodia has embarked on a programme of
reconstruction (McGrew 2010) including the development of primary health care
(Asante et al 2011). Supported by international aid, Cambodia has made
substantial progress on health indicators in the last decade. Alongside the
provision of services, the government has developed various health insurance
schemes for the poor to promote access to health care (ibid). Yet the serious
challenges remain. Cambodia has among the highest levels of maternal mortality
in Asia, and nearly two-thirds of Cambodians have tuberculosis (USAID 2011).
Malnutrition, malaria and respiratory problems are significant problems,
alongside childhood illnesses and disability due to war injuries and landmines
(McGrew 2010). The challenges are particularly acute outside of Phnom Penh
(the capital city).
5.2.3 While the number of healthcare workers per capita compares well with countries
of a similar level of development, shortages remain in many skilled areas and
48
 public health facilities lack supplies, equipment and effective systems (WHO
website, Country Fact Sheet). The Government of Cambodia Strategic Health
Plan (2008-15) acknowledges the challenge of “low salaries and lack of
appropriate motivation” which encourages a large number of public health
workers to take up additional work in the private health sector to supplement
their income (Asante et al 2011: 9). Because of this, many staff are absent from
their public sector jobs for some hours of the day (USAID 2011).
5.2.4 Paediatric emergency and intensive care: Cambodia has a high birth rate, partly
due to families trying to replace those lost under the Khmer Rouge. Almost 50%
of Cambodia's population is under 15 years of age (UNICEF website, Country Fact
Sheet). Although Cambodia’s ’under five mortality’ has decreased in the last ten
years, it still has one of the highest rates in the Asian region (ibid). The neo-natal
mortality rate also remains high, with no improvement in the last five years
(USAID 2011). Most neonatal deaths occur at birth, partly because almost fifty
percent of births take place at home (ibid). There is also a need for more prompt
diagnosis and treatment, and greater access to emergency paediatric care (ibid).
Many hospitals lack the basic equipment, staff and skills required to deal with
paediatric emergencies (UNICEF Website Country Fact Sheet). The “reduction of
new-born, child and maternal mortality and morbidity” was identified as one of
three health sector priorities in the government’s 2008-2015 Health Strategic
Plan (Asante et al 2011). Supported by donors and NGOs, the government has
embarked on various community health service and education programmes to
enhance child and maternal health care (USAID 2011). This context was the
background for the two SIF Specialist Team projects at the National Paediatric
Hospital in Phnom Penh: Paediatric Emergency and Paediatric Intensive Care.
5.2.5 Rehabilitation services for people with disabilities: A relatively high percentage
of the Cambodian population has physical and mental disabilities (McGrew
2010). This is due largely to war injuries, landmines and associated mental
health problems, alongside arthritis, hemiplegia, paraplegia, leprosy, polio,
meningitis and tuberculosis. “Many provincial hospitals perform at least 10
amputations per month, with numbers rising as conflicts continue” (ibid).
Supported by international NGOs and donors, there is a network of National
Rehabilitation Centres which provide physical therapy services as well as
appropriate technology artificial limbs and adaptive equipment. This context was
the background for two SIF Specialist Team projects (Speech therapy and
Physiotherapy) which supported networks of service delivery NGOs across
Cambodia.

49
 5.3 Vietnam

5.3.1 Vietnam is a country of nearly 88 million people (World Bank 2012). Influenced
by the Doi Moi reforms which commenced in 1989, and associated marketisation
of its economy, Vietnam is now classified as a middle-income country.
5.3.2 Since 1989, Vietnam has developed a mixed public-private approach to the
provision of health services. Health facilities are now partially financially
autonomous: they receive a government budget, but facilities, services and
salaries are topped up by facility revenues. Patients pay for services, either
through out-of-pocket payments or health insurance (including a government
health insurance for the poor).
5.3.3 Vietnam has made impressive progress on key health indicators over the past 20
years and is expected to reach several of the health related MDGs by 2015
(UNICEF 2011). Health care spending as a percentage of GDP is now high
compared to other Asian countries (WB 2010b). Yet a very large proportion of
Vietnam’s health care spending is out-of-pocket (see Table 6) and the burden of
this is most significant for the poor (World Bank 2012). Economic shock from ill
health is the most common cause of poverty in Vietnam, pushing an estimated
three million people per year below the poverty line (Thanh et al 2010).
5.3.4 A significant challenge for the Vietnamese health service is patient over-crowding
in central and provincial hospitals. While central hospitals are intended to
provide specialised services, a large number of patients with basic medical
problems travel to these hospitals for care (RTCCD 2011). This is due to the
limited health services available at the district level. In central hospitals,
overcrowding averages at 150%, with two to three patients per bed in some
hospitals (ibid). This overcrowding creates significant challenges for staffing,
patient management, sanitation and the quality of care (ibid).
5.3.5 Palliative care: In Vietnam, 150,000 people are diagnosed with cancer each year
and there are a growing number of children living with both cancer and HIV
(Green et al 2006: 11). Three central hospitals in Vietnam now provide palliative
care services, yet “palliative care training is limited and rather outdated” (ibid:
27). A 2005 study of palliative care units in Vietnam found that 85% of health
leaders felt that palliative care services in Vietnam are inadequate due to the lack
of training and guidelines. The same report noted that health care workers lack
the basic skills to assess and treat pain and depression, and that pain
management medications are not well understood and often unavailable. The
cultural context of medical services in Vietnam also affects palliative care
counselling services – there is a belief that terminal illnesses should not be
communicated to the person concerned, but rather to their family, to protect the
patient’s emotional well-being and their will to live (ibid: 24). In 2005, the
50
 Vietnamese government committed to scaling-up the care and support of people
living with cancer and HIV/AIDS, including a palliative care initiative. (This
context was the background for the two SIF Specialist Team projects at the
National K Hospital in Hanoi: Palliative Care and Psychosocial Palliative Care.)

The following chapters present a detailed discussion on the outcomes of the SIF Specialist
Team projects.

51
 CHAPTER 6: Outcomes for individual trainees
This chapter outlines the key outcomes of the SIF projects for ‘trainees’ – individual staff of
the host agency that were directly trained by the SIF volunteers. The first two sections of
this chapter analyse the outcomes of the SIF projects on (i) technical medical skills and (ii)
professional behavioural change. Examples from particular projects are used to illustrate
contextualised capacity changes and challenges.

6.1 Individual capacity development: Hard skills

6.1.1 Enhancing technical skills and Train the Trainers (TOT) are the main focus of SIF
Specialist Team projects. The evaluation asked trainees to explain the most
useful technical medical skill which they gained as a result of the SIF project and
have used regularly in their work with patients. Although each of the projects
focused on a different medical specialisation, there are some common themes
which can be discerned (see Figure 2). In this section, these common themes are
used as an entry point to discussion of individual technical capacity development,
including an analysis of the training approaches used by the volunteers and some
challenges in skills development and retention.
Figure 2: The ‘most useful’ technical medical skills developed as a result of the SIF projects

100

90
Enhanced skills for patient
80 diagnosis and assessment

70 Enhanced skills for emergency

medicine
60
Skills to use equipment
50
43% 41% 39% Counseling-communication
40 technical skills
38%
32%
30 Upgrading of theoretical
29% knowledge
20 21%
Physical therapy skills
10
Advanced specialist surgery skills
0
"What were the 'most useful technical-medical skills' you
gained as a result of the SIF project?" (Total number of
individual respondents = 92)

52
 Upgrading of technical knowledge

6.1.2 In all of the SIF projects, the volunteer teams helped to upgrade and update the
technical knowledge of host agency staff. This was largely approached through
lectures or classroom-style teaching and reinforced through practical sessions
with patients or in surgery. Many trainees perceived that their enhanced
theoretical knowledge was one of the most useful outcomes of the SIF project,
largely because it moved their knowledge forward and underpinned the new
techniques they were taught. Another common perception was that Singapore is
an advanced country, so the theories are up to date, and this gave the trainees
confidence in their work. Many trainees commented that the volunteers had
good skills to provide training on theoretical concepts. In most projects, the
volunteers used teaching aids, such as mannequins and videos, to help explain
the theories that underpin new techniques. In the Otolaryngology project in
Vietnam, the volunteers also took a participatory approach to theory training:
Resident doctors who were trainees in the SIF project were asked to undertake
research on particular theoretical topics and to present this at the SIF volunteer
sessions – after which they received constructive comments from the SIF
volunteers and their managers and peers. This approach to training helped to
build both understanding, ownership and presentation skills.
6.1.3 Some of the trainees in the Psychosocial Skills in Palliative Care project (Vietnam)
felt that the theory they were taught was complex and therefore difficult to
apply in practice. This project introduced an area of medical knowledge that was
quite new to the trainees, which highlights the need for trainings to be pitched
very carefully at an accessible level. The lead volunteers for this project also
noted this challenge and explained that they tried to address it by shifting their
approach to one based on practical sessions with patients in the mornings, and
used particular patient cases as a basis to “The training was good because it was
explain the theory in the afternoon. very specific and detailed, with
application of different measurements,
6.1.4 The use of ‘patient cases’ as an approach
each with different levels. After the
to teaching theory was used in several training, we use a ‘body pain diagram’
other projects. In some projects, the with nerves and pain locations – the
trainees themselves made presentations patients point out their pain and we can
work out what is causing it … Before, we
on patient cases as a basis for group
just determined if the pain was too much,
discussion. Several respondents or just a little. But now we really measure
explained that this was a new and useful the level and cause of pain and what
teaching technique which deepened their treatment is needed. It really changed
our approach.” (Palliative Care project
understanding.
Vietnam)

53
 Enhanced capacities to diagnose and assess patients

6.1.5 Enhancing skills for patient diagnosis and assessment was central to many of the
SIF projects; and 43% of trainees perceived these skills as some of the most
useful that they developed as a result of the SIF project. One frequent comment
from host agency staff was that the SIF volunteers taught very useful methodical
approaches to patient assessment, which compared with the less rigorous
methods they previously used. For example, respondents from several projects
explained that they now use structured frameworks and techniques to interview
patients about their medical concerns as an important part of diagnosis, which
contrasts with their previous practice of basing diagnosis largely on physical
observations. Most of the SIF volunteer teams also taught new specialist
diagnosis skills, such as the application of skin patch tests and analysis of
allergens (Occupational Dermatology project, Indonesia), and the use of clinical
reasoning for assessment of children with learning disabilities (Speech Therapy
project, Cambodia).
6.1.6 Across projects, many trainees explained that these new approaches have greatly
improved their ability to assess patients accurately and this enables the
identification of appropriate treatment, which has enhanced successful
outcomes. As one respondent from the Physiotherapy project (in Cambodia)
explained: “Before the training, I did not do good diagnosis on patients. Because
of this, in treatment I just used all of the techniques. But now it is different
because we assess the patients, using hand-feel and sometimes machine, then
we know the problem, and we apply just one treatment technique – which is
more effective.”

Consolidation and upgrading of emergency medicine skills

6.1.7 Five of the SIF projects in this evaluation “The [SIF volunteer] training had
supported capacity building in hospital many impacts…. Now the patients
specialisations that provide life-saving trust us more, so patients choose
services. While the staff of these host RSSA over other hospitals, including
private hospitals. Before our image
agencies are qualified medical practitioners, was quite bad, we didn’t treat
in some cases they have not received people well and the response times
training for work in their specialist area. were slow. Now we are known to
be one of the best emergency
Several of the SIF volunteers also noted
departments in Indonesia. The
there were large variations in the capacities patients appreciate our skills now.”
of individual staff and techniques being (Traumatology project, Indonesia)
used, a lack of coordinated teamwork, and a
need to update approaches. Due to this, in three of the projects the volunteers
started by consolidating and updating existing skills, to get all staff up to the
54
 same level and to promote a unified approach, and then gradually progressed to
more advanced skills.
6.1.8 While the five projects had different objectives, there are some common themes
in the techical skills gained from the SIF project that host agency staff found most
useful. These include updated skills for basic and advanced life support,
advanced skills for resuscitation, skills for triage assessment, and the use of
equipment such as DC-shock for cardiac arrest, and Intraosseous Infusion (IO)
injections which are administered through the bone.
6.1.9 Across the host agencies, trainees explained that the use of the new technical
skills, alongside stronger teamwork and more coherent systems, has created
faster and more accurate treatment, which has helped to reduce mortality rates
in the hospital (see Chapter 7). Particularly in the Paediatric Emergency and
Paediatric Intensive Care projects (Cambodia), the specialist training has helped
to build confidence among doctors and nurses, which has also increased
confidence and trust from patients.
6.1.10 There were some noted challenges in the use of the skills, however, most of
which relate to a lack of equipment and resources. For example, a large number
of respondents from the two projects at the National Paediatric Hospital in
Cambodia explained that their new use of IO injections has helped to save
numerous lives each week. Yet the hospital has presently got no supply of IO
needles, which are disposed after use, due to a lack of financial resources.
6.1.11 In one of the host agencies that provides lifesaving services, the volunteer
explained that some of the more skilled host agency staff were initially insulted
by the approach of ‘going back to basics’ and were more used to international
assistance in the form of equipment donations. This highlights the challenge of
mediating between volunteers’ perceptions of training needs and the
expectations of host agency staff. It also highlights the challenge of targeting
training at the right level for trainees with different ability ‒ in this project, 75%
of nurses felt that some of the skills they were taught were too advanced, yet
this challenge was not mentioned by any doctors.

Skills to use equipment

6.1.12 Some 39% of respondents felt that one of
the most useful technical skills they gained
from the SIF project was the use of
specialist equipment. Seven of the SIF
projects included training on the use of
equipment such as ventilators, pneumo-
oxygenators and DC-Shock for cardiac
“Before we didn’t know how to interpret
the electrocardiogram tests, only the
doctors did it. But after the training, we
know how to differentiate between a
normal and pathological test result, so
we now know if the patient is in danger.
If we see problems we call the doctor
right away. Many patients have been
saved this way” (Cardiac Nursing
project, Vietnam)

55
 arrest. In Cambodia, two of the projects provided training on equipment that
had been donated to the host agency by international NGOs, but was sitting
redundant because the staff had not been trained on its use. A few of the SIF
projects included donation of equipment which the volunteers then trained the
host agency staff to use.
6.1.13 Two of the projects also provided training for nurses on equipment that was
previously used only by doctors. For example, in the Cardiac Nursing project
(Vietnam) and Emergency Nursing project (Indonesia), nurses were taught how
to use DC-shock equipment and how to interpret electrocardiogram test results,
which had previously been the preserve of doctors. Many nurses explained that
this has helped to increase emergency response times and to build a greater
sense of responsibility and motivation among nurses.
6.1.14 However, a lack of equipment availability was one of the most common
problems noted in the evaluation, particularly in relation to the sustained use of
the new technical skills that were developed
“After the training, I think the
as a result of the SIF project. In some cases, knowledge I received was
the SIF volunteers trained host agency staff to amazing. But we don’t have
use equipment that was not yet available in equipment. Without equipment to
practice on, we forgot lots of the
the host agency – sometimes they travelled knowledge.” (Emergency Nursing
from Singapore with the equipment. But in project, Indonesia)
most cases, this challenge was caused by the
equipment breaking down and a lack of in-country technical support to repair it,
or there being just one piece of equipment in the host agency which was not
enough for all staff to use it and so retain their skills.

Advanced specialist surgery skills

6.1.15 Two of the projects shared specialist surgery skills with host agency staff
(Otolaryngology project Vietnam, and Reconstructive Surgery Indonesia). All of
the host agency respondents for these two projects recorded their use of more
advanced specialist skills as the most
significant outcome of the SIF “Functional Endoscopic Sinus Surgery is a
modern technique. It utilizes a localization
project. Some of the most machine that was not available in Vietnam
commonly mentioned outcomes of before the training from SIF.… When
the new advanced skills are the applying this new technique, I am able to do
ability to offer new forms of surgery advanced operations and to avoid
complications. This has improved the
to patients, greater precision, faster success rate and reduced hospitalising
surgery, updated techniques and periods from 10 days down to 5 days.”
more successful outcomes for (Otolaryngology project, Vietnam)
patients.

56
6.1.16 One challenge has been the difference between the equipment available in the
host countries and in Singapore, and this has often required adaption of the
techniques. Because of this challenge, 50% of the respondents for the
Reconstructive Surgery project felt that some of the technical skills that the
volunteers shared were too advanced, or were not relevant. This challenge was
noted by only one respondent in the Otolaryngology project, which may reflect
the adjustments made to this training programme after the volunteers realised
that it was too advanced.

Enhanced counselling and therapy skills

6.1.17 Two of the SIF projects built staff capacities to use counselling and psychological
approaches in patient care: the Psychosocial Skills in Palliative Care project
(Vietnam) and the Speech Therapy project (Cambodia). Trainees that
participated in these two projects explained that they now use new technical
approaches such as non-verbal communication with children, assessments of
emotions, family support and group therapy.
6.1.18 A notable outcome among trainees of both projects is a new appreciation of the
need for psychological approaches within treatment programmes. For example,
nearly all of the trainees in the Psychosocial Skills in Palliative Care project
explained that they had previously focused only on the body and use of
medicines, but after the SIF project they pay greater attention to the patient’s
mind and are able to support patients psychologically. However, in both of these
projects, some of the respondents felt that some of the psychological concepts
they were taught were very new and quite complex and so difficult to
understand. Due to this, some of the skills are not being applied in practice.
6.1.19 Trainees in the Psychosocial Skills in Palliative Care project noted a particularly
wide set of challenges in the use of the new skills. Due to patient over-crowding
in the hospital, most of the respondents explained that they do not have time to
use the new skills in any depth “‘Before the training, we only applied our general
because they could only spend knowledge and our approaches were very
a few minutes with each passive, but after training we use proper
techniques.... The Singaporeans [volunteers]
patient. Several staff and one
taught us to give children choice in the therapy,
manager also feel strongly that to encourage them, even if they cannot speak
palliative care staff should not they can blink their eyes. We now know that it is
take on this new role (which is not good to force them. With the new skills I can
now help kids to stop drooling, to strengthen
taken on by separate staff in their molar muscle and stimulate senses around
countries like Singapore) on top their mouths. Now we have much better results
of their existing heavy than before.”’ (Speech therapy project,
workload. A few staff also felt Cambodia)

57
 that some of the approaches which the volunteers shared, such as group
therapy, are not appropriate in Vietnam because patients are not comfortable
talking about emotions in public. Also, doctors in Vietnam do not usually talk to
patients directly about death. The volunteers also explained that the process of
sharing skills with host agency staff had involved a lot of discussion on
appropriateness and how to adjust the skills to the local context. Although most
of the trainees do use some of the counselling skills in their daily work with
patients, there are limits to their use.

Enhanced physical therapy skills

6.1.20 Two of the projects supported the development of physical therapy skills: the
Physiotherapy Project and the Speech Therapy project (both in Cambodia). In
both of these projects, the trainees
were individuals from different service Before the training, doctors were the
only instructors, but now nurses can also
delivery NGOs (or different public do it, nurses have their own work
hospitals). The training approaches independent of doctors now. For
were quite different however. The example, we ask about a patient’s
participants in the Speech Therapy condition and give them instructions.
We manage and read cardiograms... run
project, who work with children with the artificial heart and lung machine’.
disabilities, had not previously used (Cardiac Nursing project, Vietnam)
speech therapy skills. The lead
volunteer for this project explained that the existing capacity of many trainees
was very low, so the project just aimed to share a small set of basic skills ‒
“perhaps just 5% of what they needed to know to provide quality speech therapy
services”. In contrast, the physiotherapy project was based on development of
a formal advanced certification course for qualified physiotherapists, which the
volunteers directly taught in the initial few years. Between volunteer visits, the
trainees were expected to revise and research. An unusual aspect of this project
is that a full-time international missionary-volunteer (not related to the SIF)
became involved in the project. As an Australian physiotherapist who is fluent in
Khmer language, he facilitated technical mentoring between the SIF volunteer
visits, and also helped to mediate relationships between the SIF volunteers and
host agency staff. His sustained involvement, and ability to teach in the local
language, was important to the development of solid technical skills.
6.1.21 Staff from both of these host agencies explained that they had not previously
used specialised therapy skills. For example, several physiotherapist respondents
explained that they previously just ‘gave patients a massage’. In both projects,
the trainees explained that their use of the new skills has greatly improved the
success of treatment, and also their professional confidence.

58
6.1.22 One challenge common to these therapy-based projects is that the use of the
new skills is quite dependent on the commitment and motivation of the patients
and their care-givers (a challenge noted by 80% of trainees from the Speech
Therapy project). For both the Speech Therapy and Physiotherapy projects, 20%
of respondents that felt some of the skills were not relevant to them, largely
because their NGOs tend to specialise in a few medical issues. In the
Physiotherapy project, another noted challenge in the use of the new skills was a
lack of technical supervision within their various organisations (noted by 40% of
trainees). This challenge is shaped partly by the design of this SIF project ‒ it
involved individuals from various organisations (rather than building the skills of
an existing team). Also in this project, 30% of trainees experienced a lack of
cooperation from their colleagues, particularly the staff of public hospitals,
where some doctors don’t always recognise physiotherapists and so prescribe
medicines instead of referring patients to them. This highlights some challenges
in the project model which engages individuals from other organisations, as
discussed further in Chapter 7).

6.2 Sustainability in the use of new technical skills

6.2.1 The discussion above has highlighted that many of the technical skills shared by
the volunteers have become central to the daily work of host agency staff.
Sustainability has been enhanced by the holistic approach to training taken in
most of the projects, from diagnosis to treatment and monitoring. In several
projects, this has promoted a new pathway for technical work within the host
agency.
6.2.2 Sustainability in the use of new technical skills has also been enhanced by the
development of formal protocols and guidelines which help to institutionalise
the new techniques and importantly, give authority for their use. In a few of the
host agencies, the use of the new technical skills has not been formalised by their
integration into protocols. In these organisations, a few trainees noted a
challenge of some colleagues (who were not trained by the SIF volunteers) not
recognising the new skills – and where the colleague was more senior, it was
difficult to use the skills while under their supervision.
6.2.3 The most frequently mentioned challenge for sustainable use of the skills is a lack
of resources within the host agencies. This affects the availability of both
equipment and supplies (such as the special wound dressings used in Singapore
and IO needles). A lack of human resources (understaffing) is also a significant
challenge in many of the host agencies, and particularly affects the time available
to use psychosocial skills in palliative care.

59
 6.3 Individual capacity development: Soft skills

6.3.1 Staff from all 12 projects expressed quite significant changes in professional
behaviour, and many host agency respondents perceived these changes to be
among the most important outcomes of the SIF project.
Figure 3 outlines some of the key behavioural changes resulting from the SIF projects, as
perceived by host agency staff.

Figure 3: Changes in professional behaviour influenced by the SIF project

100
Enhanced empathy &
communication with patients
80 74%

63% Improved team work & team

60 56% communication

41% Changed mindset: motivation,

40 professionalism & confidence

20 35% A new patient centred approach:

medical ethics & equity

0 Greater attention to sanitation &

% of respondents who perceive that they have achieved different safety
types if behavioral change as a result of the SIF project (number of
individual respondents = 92)

Enhanced empathy and communication with patients

6.3.2 Across the host agencies, one of the most

“The training completely changed the
frequently mentioned outcomes of the SIF
way I communicate with patients. For
projects has been enhanced communication example, after diagnosing I now explain
with patients (mentioned by 74% of to patients about their illness and
respondents). In many host agencies, staff discuss possible treatments with them.”
(Otolaryngology project, Vietnam).
explained that they had not previously taken
time to interview patients about their ‘‘The Singaporean [volunteers] taught
medical problem or to explain illnesses and us actions in diagnosing, touching a
procedures to patients; but after their work patient’s arms and padding a patient’s
shoulder, which are all actions to sow
with the SIF volunteers, they now see this our sympathy. I am gentler now.”
communication as central to their work. (Palliative Care project, Vietnam)
6.3.3 Many respondents also spoke of a new empathy with patients, more gentle and
caring interactions, listening to patients and building trust. One important

60
 outcome of this communication, mentioned by respondents in three projects, is
a new ability to successfully counsel patients into accepting lifesaving or life-
changing treatment. While four of the projects included training sessions on
patient communications, most of the respondents explained that the changes
were most influenced by working alongside the volunteers in patient
consultations and ward visits.

Enhanced team communication and collaboration

6.3.4 Many of the SIF projects have also

“We now know that we need to have
influenced better communication and mutual understanding and solidarity,
collaboration within staff teams and if we make mistakes we need to
(mentioned by 63% of host agency staff). discuss together …. There is a change in
the attitude of my colleagues – now they
Many respondents explained that they cooperate to rescue the patients. For
previously focused just on their own job, example, in the case of emergency, even
but now they share responsibilities and if it is not their responsibility they help
support each other to achieve common each other upon request to rescue the
patients. This is unity.” (Doctor,
goals. Host agency staff also explained Paediatric Emergency project,
that they now communicate effectively as Cambodia)
a team when treating patients, and are
more responsive to each other in medical emergency situations. This change
was most influenced by the volunteers’ practical guidance in work with patients,
in which they promoted staff communication and illustrated teamwork through
their own actions. In some projects, the change was partly shaped by the
volunteers’ promotion of new team systems, including more defined roles for
each team member. The training attachment in Singapore was also a large
influence ‒ many respondents explained that their exposure to the Singapore
medical context made them realise the importance of teamwork and that
effective communication can enhance patient care and help to save lives.
6.3.5 For some projects, trainees spoke particularly about enhanced communications
between doctors and nurses. This change has often been underpinned by a new
independent role for nurses, as discussed next. Several nurses also explained
that the SIF volunteers helped them to understand that they have unique
knowledge, such as understanding of patient emotions and responses to
medication, and that communicating this to doctors can enhance patient care.
Some respondents also explained that the volunteers helped doctors to
understand that their communication with nurses is critical to patient care: such
as clearly explaining how to administer medicines.
6.3.6 A new independent role for nurses: In four of the host agencies, the SIF projects
helped to create a more independent role for nurses. In these host agencies,

61
 nurses explained that they had previously awaited instruction from doctors,
often sitting in a central area, meanwhile patients were not being monitored.
Nurses explained that they didn’t have the authority or confidence to play an
independent role, and doctors treated them as their assistants. The SIF
volunteers helped to create more independent role for nurses through
enhancing their skills and understanding of their role, as well as work with host
agency management to support the development of new job descriptions. One
nurse did note, however, that the SIF volunteers needed to appreciate that
nurses in Vietnam do not work independently from doctors (which suggests that
the change was not well-received by all staff).

‘Changed mindset’: Enhanced motivation and professionalism

6.3.7 Slightly more than half of the trainees “After the training, learners were more
(56%), from nine of the 12 projects, active in their work. We also changed our
perceived that the SIF volunteers perspective and the way we took care of
helped to enhance staff motivation and patients, which increased the result of the
treatment, especially in difficult cases.”
professionalism. Many respondents (Cardiac Nursing project, Vietnam)
referred to their greater sense of
responsibility for their work and for “After the training we follow the Singapore
system, we are more disciplined in our
overall patient care. When explaining approach, we are more professional, like
their enhanced professionalism, many hard work and time keeping. I am proud of
respondents gave examples which my work and more motivated now and
related to their own actions, such as take more responsibility.” (Traumatology
project, Indonesia)
better time-keeping and discipline in
working practices, greater attention to accurate diagnosis and re-assessment of
patients; or more attentive patient monitoring and more methodical approaches.
Some respondents also related enhanced professionalism to their wider
organisation, such as more structured systems and documentation processes.
Nurses from various projects explained that their greater sense of responsibility
at work was influenced by their realisation that their work has real impacts on
patient recovery.
6.3.8 Changes to professionalism were most often explained as an outcome of working
alongside the volunteers over time, and being inspired by their approach to
work. Many trainees also made a link between their ‘enhanced sense of
responsibility’ and increased motivation, both of which were related to their
greater success in their work with patients.
6.3.9 The volunteers for some projects in Vietnam and Cambodia explained that a
‘negative mindset’ about learning among trainees had been an initial challenge
for the project. As one volunteer explained, “The nurses didn’t want to learn,

62
 because new knowledge means more work, and they said that their salaries were
too low, they could not do additional work.” While the senior managers in the
host agencies collaborated with the SIF and volunteers to design the project,
some of the trainees (staff in the host agency) were less willing to learn and
change. The volunteers for projects in which this challenge was felt explained
that they worked hard to get the staff on-board – such as discussing their
concerns, adjusting their teaching approaches to increase practical sessions, and
holding the trainings in the mornings so that staff could go to their private work
in the afternoon. The volunteers for each of these projects explained that most
staff did eventually become enthusiastic about learning and developing their
skills, and many staff very proudly reported the progress they had made between
volunteer visits. One volunteer expressed that “the change in mindset was the
greatest impact of the project.”
6.3.10 The discussion above highlights the influence of personal income on staff
motivation, including their interest to learn and develop their skills. In some
cases, the skills taught by the volunteers can be used in private sector work (such
as physiotherapy). Other projects focused on skills that cannot easily be used in
the private sector. In one project, interviews with staff indicated that motivation
remains a challenge ‒ influenced by low incomes, alongside the fact that many
staff had not chosen to be placed in the new department and find the work
arduous and emotionally draining.

A new patient-centred approach: Medical ethics and equity

6.3.11 A significant number of respondents (41%, “Before SIF training, we treated the
from eight of the 12 projects), explained patients without their consent. Now,
that the SIF volunteers promoted a new after the SIF training, we ask for
consent. These are the ethics that
patient-centred approach which they now
the SIF [volunteers] taught us.”
use in their daily work. This includes a new (Emergency Nursing project,
focus on patient choice, privacy and Indonesia)
consent, as well as wider medical ethics
and promoting patient engagement in their treatment. Increased attention to
patient choice and consent was often linked to enhanced communication with
patients. Respondents from four of the host agencies explained that, influenced
by the SIF volunteers, they now explain different treatment options to patients,
and provide advice to the patient on the best option and ask for the patient’s
informed consent. In terms of patient privacy, the examples given by host
agency staff include asking the permission of patients before touching them, and
protecting patients’ privacy when undressing them or attending to their wounds.

63
6.3.12 The two projects in Indonesia which supported the introduction of triage also
promoted a more equitable approach to patient management and care. Many
staff explained that the volunteer training on the new triage system helped them
to recognise the need to deal with patients in critical conditions before patients
with wealth or connections to hospital staff. One doctor explained: “Before, we
handled patients that could not pay as a last priority. Now we don’t do this, so
their lives are being saved. This is the new triage system. Patient survival is now
the highest priority.”

Increased confidence

6.3.13 Almost a quarter of respondents (24%) explained that their confidence has
increased as a result of the SIF project. This was largely related to enhanced
technical capacities and seeing improved “Doctors don’t get nervous now, they are
results in patients, as well as a more confident. This also helps reduce
perception that the training had provided the nervousness of the children and their
them with grounded skills. For example, parents. Now if the patients die, the
parents seem more able to accept the
50% of participants in the psycho-social fact, they know that the doctors try very
Palliative Care project in Vietnam hard to do their best. This is different to
explained that they are now more before.”. (Paediatric Emergency project,
Cambodia)
confident in their communication with
patients. A significant number (37%) of doctors who participated in the
Reconstructive Surgery project, Indonesia, referred to their greater confidence in
surgery as a result of the SIF project, which several staff related to the very
practical way that the skills had been taught, and also to the significantly more
successful outcomes of surgery. The projects that focused on Emergency
Medicine also built significant staff confidence, and some respondents
(particularly from the National Paediatric Hospital in Cambodia) spoke of being
calmer and less nervous when handling patients in critical conditions.

Greater personal attention to infection control and safety

6.3.14 Many of the SIF projects have also increased host agency staff attention to
sanitation, infection control, safety and hygiene (mentioned by 35% of
respondents). This includes new hand-washing routines, wearing gloves when
handling chemicals, careful disposal of wound dressings and needles, wearing
closed-toe shoes and sanitising of equipment. In some cases, these practices
have helped to develop new systems and norms within the host agency, such as
the provision of boxes in which to dispose of needles, and efforts to increase
spacing between beds.

64
 CHAPTER 7: Organisational capacity development
In addition to building individual capacities, all of the SIF projects influenced some
improvements to the host agency’s systems and processes. The scope of these changes
varied greatly: some projects aimed to influence significant changes in organisational
processes from the outset, while others affected smaller changes (such as the redesign of
patient assessment forms) as the project progressed. In several projects, organisational
systems became a focus of the project after the volunteers gained better understanding of
the host agency contexts, and the way that weak systems affect overall capacity ‒ including
the ability to use and sustain new individual technical skills. As explained in detail in
Chapter 3, organisational capacity has five core components:

 Internal systems and coherence

 Internal organisation and action
 External networks and external recognition
 Learning environment
 Development results – service delivery and outcomes for patients

Using these five core themes, the analysis in this chapter reviews the impacts of the SIF
projects on organisational capacity development.

7.1 Internal systems and coherence

7.1.1 Weak internal systems were identified by the volunteers in most of the host
agencies. For example, many of the host agencies had weak patient
management systems and a lack of clear guidelines, as well as a lack of
coherence in work processes and team systems. This was a challenge to the
overall capacity of the host agency. This section summarises some of the
changes to organisational systems and coherence which were achieved as a
result of the SIF Specialist Team projects.

65
Figure 4: Changes to internal coherence as a result of the SIF projects

12
New Protocol or guidelines

10
New patient management &
documentation systems
8 More systematic patient
assessment & monitoring
6 More coherent team structures
and roles
4 Improved general organisation
systems
2 Better coordination with other
departments
0 Clearer stepped approach to
Number of SIF projects in which different types of internal emergencies
coherence were enhanced (total number of projects = 12)

New patient management and documentation systems

7.1.2 In nine of the projects, the volunteers “The SIF [volunteers] introduced triage
helped to enhance patient management to our hospital - how to assess and
and documentation systems. For example, prioritise the patients into categories
P1/P2/P3, and provide the appropriate
the volunteers guided the development of
action. Triage was applied in the mass
new patient record and monitoring forms. food poisoning case. We differentiated
These forms link with the new systematic the patients and gave each a different
approaches to patient diagnosis and colour bracelet, depending on how
serious their condition was. I am very
monitoring which the volunteers had
impressed with this experience. I can
taught, and so helped to structure and monitor easily with this way.’ (Doctor,
sustain the use of these skills. In the Traumatology Project, Indonesia)
Palliative Care project (Vietnam), the new
“Our internal processes did not change
patient documentation forms have a very much. After the training we
dedicated section for nursing inputs, which applied as many skills as possible to
some has helped to promote a sense of our work. However, we could not
change everything due to our
responsibility among nurses As part of
circumstances of overcrowding.”Nurse,
the traumatology project (Indonesia), the Cardiac Nursing project, Vietnam)
volunteers also developed a new registry
system for patient records, which has been used to support departmental
planning (see Section 7.2).
7.1.3 In the four host agencies that handle emergency medical care, the volunteers
introduced (or enhanced) triage systems. Triage involves the categorisation of
patients into three levels of priority, using standard processes and assessments.
The new and enhanced triage systems have had large impact on patient

66
 management; and because this system promotes immediate attention to the
most urgent cases, many trainees explained that it has helped to save lives. As
part of the Traumatology project, the volunteers also guided the structural
redesign and reorganisation of the department, so that it was more conducive to
triage and rapid response to medical emergencies.

More coherent team structures and roles

7.1.4 In eight of the projects, the SIF volunteers helped to enhance team systems, and
the creation of more defined staff roles. In the departments and units that were
newly created (shortly before or during the SIF project), the volunteers helped to
design staffing structures, roles and rostering systems (for example in the
Occupational Dermatology host agency in Indonesia and the Paediatric intensive
Care host agency in Cambodia).
7.1.5 In five host agencies, the volunteers introduced a clearer system of staff roles for
medical emergency situations: Each attending staff member is given a ‘numbered
role’ (Nurse 1, Nurse 2, etc.) that identifies where they should stand in relation to
the patient and the tasks for which they are responsible.
7.1.6 In the Cardiac Nursing project (Vietnam) The system for cooperation between
and Emergency Nursing project people in my group is definitely better.
(Indonesia), the volunteers helped to For example, when there’s a cardiac
standstill case, each person knows their
create more defined roles for nurses. In
job – pressurizing the heart, pressing the
both host agencies, nurses had previously air ball, giving medicine, etc. We have a
gathered in a central area awaiting system now, and each person already
instructions from doctors, meanwhile knows their duty, everything is carried
out quickly. Within 3-4 minutes, the
patients were not being monitored. The
patient is able to recover’. (Nurse,
volunteers supported the host agencies Cardiac Nursing project, Vietnam)
to assign particular tasks to nurses (such
as ongoing nursing care and patient monitoring) which have become their
responsibility. These tasks are coordinated with those of other team members,
for example many nurses explained that they know to alert doctors if
electrocardiogram readings suggest an emergency situation.
7.1.7 Five of the volunteer teams also promoted multi-disciplinary team work, where
there had previously been a lack of coordination between specialisations, e.g. in
the Reconstructive Surgery project in Indonesia, microsurgery and craniofacial
surgery are now carried out by multi-disciplinary teams, whereas previously
patients had required several separate operations from different specialists.

67
 More structured systems for patient care

7.1.8 Nine of the volunteer teams supported the introduction of more systematic
approaches which are now institutionalised in the host agencies. One important
change in the emergency medicine host agencies has been the introduction of a
clearer ‘stepped approach’ to emergency treatment, including the provision of
quick-reference charts.
7.1.9 More structured systems for patient “We now have a more systemised
assessment were promoted by several way of giving medicine to patients.
volunteer teams, such as defined routines After being instructed by the
volunteers, nurses do this job more
for patient monitoring (e.g. timed checks on thoroughly: they put each patients’
patient blood sugar levels) which contrast medicine into a bag, which also has
with their previous less systematic a printed prescription (with the
approach. The volunteers for the name of the medicine, amount and
doses). This acts as a proof of trust
Occupational Dermatology project between patients and medical staff.”
(Indonesia) helped to introduce a new (Nurse, Palliative Care Project,
structured system for patient diagnosis, Vietnam)
including a framework for interviewing
patients and the use of skin patch tests. Similarly, in the Palliative Care host
agency (Vietnam), there is now a new system for measuring pain and its causes,
and a model for developing family trees. Some of the partner NGOs in the
Speech Therapy project (Cambodia) now use a clinical reasoning approach to
patient assessment, which provides a clear structure for assessments and a new
process of reassessment. This approach also encourages peer engagement
through patient case meetings. These models provide a more structured
approach and help the staff to identify appropriate treatment.
7.1.10 The volunteers for four of the projects promoted the introduction of ‘instruction
leaflets for patients’, such as on physiotherapy exercises to do at home or
printed instructions to accompany medicine prescriptions. This structured
approach has helped to enhance patient self-care.

Better coordination with other departments

7.1.11 Five of the SIF projects helped to enhance
coordination with other hospital
departments. This has helped to promote
coherence within the wider organisation.
For example, at the National Paediatric
Hospital in Cambodia, the volunteers
helped to set up a system for patient
referral between the emergency and
“The department was created in 2002.
At that time, when a severe case came,
we were so nervous because we didn’t
know how to deal with it. I could not
even find the intubation machine!
After the [SIF volunteer] trainings, the
change is 180 degrees.” (Manager,
Paediatric Emergency project,
Cambodia)

68
 intensive care departments, with associated joint guidelines and documentation
processes. Three of the projects also guided systems to enhance coordination
with specialists in other departments (such as between reconstructive surgery
and the psychology department). This strengthened coordination was initially
fostered by including individuals from these departments in the volunteer
trainings. The structure and process of the Emergency Nursing SIF project
(Indonesia) also promoted stronger coordination between the hospital and
nursing department of the local university.
7.1.12 In some host agencies, coordination with other departments has been a
challenge. For example, in the Traumatology host agency (Indonesia), the lack of
cooperation from other hospital departments has been a problem for successful
integration of referral systems and specialist training placements. The volunteers
for the Paediatric Intensive Care project (Cambodia) also tried to strengthen
inter-departmental coordination, which was achieved to some extent (for
example with the X-Ray and services departments), but has not yet been
achieved on a wider scale.

Improvements to general organisation systems

7.1.13 In half of the projects, the volunteers

“We developed an SOP for microsurgery
helped to improve general based on the SIF training, including
organisation systems, such as the information for the emergency
storage and labeling of medicines, department that you should only try to
reattach fingers within 5 hours of
quick-reference posters for amputation. The SOP was endorsed by
emergencies, drug charts and the hospital as a whole. Because the
equipment checklists. In many of the emergency department follows the SOP,
host agencies, weak organisation more microsurgery is done more quickly
and more successfully. We coordinate
hampered overall capacity and safety. better and faster within the hospital.”
One common example, in the host (Doctor, Reconstructive Surgery project)
agencies that manage medical
emergencies, is a lack of emergency medicine trollies and no defined place for
storage of emergency equipment, which significantly slowed down emergency
care. The volunteers helped the host agencies to identify such challenges and
supported development of more organised systems.

New protocols or guidelines

7.1.14 Nine of the host agencies have developed new guidelines or protocols related to
the techniques and systems which were introduced by the SIF volunteers. This
was most notably achieved by the Indonesian host agencies, which have each
developed or updated Standard Operational Procedures (SOPs), which explain

69
 departmental systems as well as particular medical techniques and required
equipment and consumables. The integration of the new techniques and
systems into SOPs has authorised their use, and enables patients to claim for the
associated medical care on their government health insurance. In Vietnam and
Cambodia, some of the host agencies had not previously developed protocols,
and have found that their development usefully promotes unified approaches,
systems and routines.
7.1.15 Among the projects that did not result in the development of new protocols, one
trainee explained that “We don’t have a protocol yet, but we may set it up.
Basically, the training was very specific and had a small focus, so it is difficult to
influence the internal policy, which was designed long ago.”

7.2 Internal organisation and action

7.2.1 Internal organisation and action requires strong leadership and planning, as well
as adequate sources of funding.
7.2.2 When asked directly, 41% of host agency managers felt that the SIF project had
not impacted on leadership or management skills. In most cases, host agency
managers explained that the volunteers had “They were nice, disciplined, and
focused on building the capacity of the staff consistent. But sometimes we
rather than the managers. A few found it difficult to manage with
their system (e.g. discipline in
respondents also felt that the project was too Singapore), this is why we could
short to influence leadership and planning not apply the whole system here,
skills, that there has been large movement or especially the soft skills in the
retirement of management since the SIF management. In Singapore they
work very fast and have different
project closed, or that the management working styles.” (Emergency
systems in Singapore were too different to Nursing project, Indonesia)
their local working styles.
7.2.3 However, many other host agency managers and staff felt that the SIF projects
helped to increase awareness of the need for leadership and planning skills,
including clear staff responsibilities, coherent systems and forward planning. In
one of the host agencies in Indonesia, for example, a manager explained that the
SIF project inspired greater planning, not only for purchases of supplies and
equipment but also for staff capacity development. In another host agency,
influenced by the SIF project, managers were inspired to prepare technical
protocols to provide clear guidelines to staff – which had not previously been
done in the organisation.
7.2.4 Several respondents also explained that the SIF projects had directly impacted on
the quality of leadership in their organisations. The most common explanation
for this was that a fairly large number of the trainees in the SIF projects have now

70
 been promoted to management positions, and they are strong and active leaders
because of the enhanced professionalism, knowledge and motivation they
developed as a result of engagement with the SIF volunteers. However, several
of the same respondents also noted that the people that have been promoted to
management positions are now not practicing their technical skills, and this is a
loss because they were some of the most skilled practitioners. Several managers
also explained that enhanced leadership and planning skills were illustrated
through their successful implementation of various impressive changes during
and after the SIF project (such as new staffing structures, internal systems and
protocols), which may imply that the SIF project was a catalyst for more active
leadership. One of the host agency managers for the Traumatology project
(Indonesia) explained: “After the [SIF] project, our better leadership was
recognised by donors and this led to more funding.”
7.2.5 In terms of new leadership and planning systems, some trainees in the
Emergency Nursing project (Indonesia) said that the SIF volunteers taught them a
management process of ‘Plan, Do, Control and Action’ (PDCA) which has helped
head nurses to organise processes and roles in the department. As part of the
traumatology project, the volunteers also developed a new registry system for
patient records. This registry system has been used to generate statistics on
patient handling speed and recovery rates, which is used to support planning.
7.2.6 Some of the SIF projects also influenced recognition of the need for leadership
training. For example, one manager from the Reconstructive Surgery host agency
(Indonesia) also said that they SIF project had led to a new recognition of the
need for planning skills, which had prompted them to send some staff on a
planning course (separate to the SIF project). Six staff of the Paediatric
Emergency host agency (Cambodia) were also invited to a management training
at the Singaporean hospital in which the volunteers work (the hospital funded
their attendance, after the SIF project closed).

Funding and resources

7.2.7 The lack of financial resources is a challenge for all of the host agencies (noted by
63% of respondents). However, 42% of respondents felt that their organisation
had gained some additional resources “Leadership and planning was
after the SIF project closed (such as improved in many ways, and this was
funding, equipment, books or physical recognized by other donors and they
then gave funding, so we can continue
structures) to help implement the new
to develop.” (Traumatology Project,
skills and systems they learnt in the SIF Indonesia)
volunteer training.

71
7.2.8 In all four Indonesian host agencies, funds have been gained to support cascade
training and the development and running of the new university courses that
were designed with SIF volunteer support (see section 7.4). All four Indonesian
host agencies have also used government funding to purchase some equipment
and supplies that are required for the use of the new techniques taught by the
SIF volunteers. However, many respondents from these four host agencies also
noted resource challenges, such as funding being too limited to purchase
equipment and supplies of the desired quality and quantity.
7.2.9 In Cambodia, the Paediatric Emergency host agency gained funding from the
WHO to impart the ETAT training programme, and the Physiotherapy host
agency received some funds from an American Trust to help run the Advanced
Certificate in Physiotherapy course. More broadly, the host agency managers
explained that there was no additional budget gained as a result of the SIF
project and that they are mainly reliant on donation of equipment from
international organisations.
7.2.10 In Vietnam, several host agency managers explained that the government policy
which promotes the financial independence of public health providers has
limited their access to government funding. However, in 2012 the Palliative Care
host agency in Vietnam has been promised a significant budget allocation to help
develop palliative care systems such as training six other hospitals, developing a
homecare system and psychosocial care.

7.3 External networks and recognition

7.3.1 An organisation’s relationship with external stakeholders (such as patients,

government health departments and international agencies) impacts on its
capacity to operate effectively, access funding and support, and to achieve
results. In this sub-section, we review the outcomes of the SIF projects on the
host agency’s external networks and recognition from its stakeholders.
7.3.2 Respondents from six of the projects explained that they now have greater
recognition from patients, due to their enhanced skills and more successful
outcomes. A commonly mentioned indicator of “When inviting people to
this recognition is the greater numbers of participate in training, they
patients that use their services, rather than other used to ask what they would get
available public or private service providers. (How much is the per diem? Is it
paid from my accommodation?
Respondents from two of the host agencies also etc), but now we just announce
explained that they now receive notably fewer on our website, and people
complaints from patients, as a result of the register and even pay money!
enhanced individual skills and patient This is a big change!” (Manager,
Physiotherapy project)
management systems which developed as a
result of the SIF project.
72
7.3.3 Influenced by the skills and knowledge gained through the SIF project, the
trainees of four of the host agencies said they are now newly recognised as the
national centre for work in their field. All four agencies are in Indonesia, which
perhaps suggests an influence of the national context over this achievement. This
achievement is particularly notable because none of the host agencies are in the
capital city (Jakarta), which is the location of more advanced health services in
the country. (It should be noted that several of the other host agencies were
already key centres for their specialist area in their respective countries).
Figure 5: Changes to external networks and recognition due to the SIF projects

Greater recognition from patients

Host agency newly recognized as the

national centre for work in their
field

New alliances, networks and

membership of associations

Increased ability to communicate

with funders

Host Agency gained formal

recognition from international
agencies
Number of projects in which different types of external networks and
recognition were gained (total number of projects = 12)

73
7.3.4 As a result of the new knowledge and skills developed through the SIF projects,
four of the host agencies have been asked to provide training for other
organisations. In some cases, this has been a direct request from another
hospital, and in other cases this has been a request from the government health
department. Three of the host agencies have also contributed to national
technical guidelines on their specialist area (Vietnam national guidelines on
palliative care, Indonesian national guidelines on emergency medicine, and
Cambodian guidelines on paediatric emergency). This theme is discussed in more
detail in Chapter 8.
7.3.5 Managers from two host agencies explained that their interactions with SIF staff
and volunteers have enhanced their ability to communicate with funders such as
international donors and trusts. These skills have helped them to successfully
develop and sustain relationships with international organisations, and to gain
additional support for training and equipment since the SIF project closed.
7.3.6 Respondents from two host agencies explained that they have gained formal
recognition from international organisations, and this was influenced by the new
skills and systems developed as a result of the SIF project. The Saiful Anwar
Hospital in Malang received ISO certification for its Emergency Medicine SOP (its
protocol and system for emergency medical care), and later received a
commendation from USAID as the leading emergency medicine department in
Indonesia. In recognition of its progress, knowledge and skills, the WHO named
the National Paediatric Hospital in Cambodia as a national training centre for its
Emergency Triage and Treatment (ETAT) programme.
7.3.7 As a result of the SIF project, several host agencies have also expanded their
networks and alliances, both nationally and internationally. In some cases, the
SIF volunteers supported the host agencies to become members of international
professional associations (such as the Asia Pacific Palliative Care Network and the
World Confederation of Physical Therapy). This has expanded avenues for
training support as well as enabling host agency staff to engage in international
conferences at which they share their knowledge and learn from others. Some
of the volunteers also linked the host agencies with universities and specialists in
other countries beyond Singapore, who have since provided training for the host
agency. The Occupational Dermatology host agency (Indonesia) has developed
a wide range of new networks and alliances, which respondents explained as a
result of the SIF project. This includes new relationships with government
departments and factories, and new membership of national and international
professional associations – which has provided new avenues for cooperation,
sharing and learning, as well as greater recognition for their work.

74
 7.4 The learning environment

7.4.1 In most host agencies, the SIF projects had some impacts on the learning
environment, in terms of motivation to learn, new skills to teach and research,
and managerial commitment to internal training.
Greater motivation to learn

In many of the host agencies, the SIF project has had an impact on the staff’s
motivation to learn. This outcome was directly mentioned by the staff of four of
the host agencies, and inferred in many other projects by the way that
respondents spoke about their new knowledge, the results that it has enabled,
and their desire to learn more. For example, several respondents from
Cambodia and Vietnam explained that they are now more motivated to learn
and to improve their English in order to study abroad.

Figure 6: Changes to the learning environment as a result of the SIF projects

12

10 Regular cascade training, based on

10 the volunteer teaching modules

8 Enhanced teaching, assessment

7 and curriculum development skills

6 New confidence and willingness to

5
teach among staff
4 4
4
Greater motivation to learn

2
Additional funds gained to support
teaching programmes/cascade
0 training
Number of SIF projects in which different aspects of the learning
environment is enhanced (total number of projects = 12)

75
7.4.2 One particularly strong example of enhanced motivation to learn is the
Physiotherapy project in Cambodia. Several trainees from this project explained
that they are now willing to pay to attend training programmes, and related this
to the link between strengthened skills and more successful results. These
respondents also explained that their enhanced skills and results have helped to
increase their income, because they now get a larger number of private patients.
7.4.3 The influence of the SIF projects on trainees’ willingness to learn was also
mentioned by several of the volunteers, in a way that usefully illustrates the
process of change. As explained in section 6.3, the volunteers for some of the
projects in Vietnam and Cambodia admitted that a ‘negative mindset’ about
learning among trainees had been an initial challenge for the project. In some
cases, negative mindsets were influenced by low salaries and generally low
morale. Most often the volunteers tackled the challenge by discussing concerns
in the training sessions, and made changes to their teaching approaches in
response to the concerns (such as facilitating more practical sessions, and timing
training sessions in a way that enabled staff to go to their private work in the
afternoons). By the end of the projects, according to the volunteers, there was
significantly greater enthusiasm for learning and developing skills among the
staff of most projects. This enthusiasm for learning was illustrated in the
interviews with trainees in most of the projects, with the exception of the one
project where staff morale remains low (see Section 6.2).
7.4.4 Several of the projects also helped to develop new research skills and
approaches, which have been used by the trainees since the project ended. In
most cases respondents spoke about research skills to update their technical
knowledge, but some managers also referred to forms of empirical research. For
example, the volunteers for the Occupational Dermatology project (Indonesia)
helped to develop the trainees’ skills for data collection and analysis, which the
trainees have used to undertake detailed research on skin diseases at the factory
clinics set up through the SIF project. The manager of the Traumatology host
agency in Indonesia has also used the new patient registry system (which was
developed with guidance from the SIF volunteers) to generate statistics on
patient’s medical problem, treatment and recovery time, which has been used to
understand patient flows and to inform subsequent planning.

Cascade training for staff within the host agency

7.4.5 Cascade training of the SIF teaching modules within the host agencies is one
example of managerial commitment to staff development. Since the SIF project
closed, ten of the host agencies have facilitated fairly substantial and regular
internal trainings, based on (or including) the SIF volunteer teaching modules.

76
Table 8: Modalities used for cascade training

Regular Integration of ‘SIF

Formal Formal
cascade volunteer teaching A feedback
Cascade training higher Teaching certifica-
training in modules’ into a session for
modalities education Hospital tion
the host funded national colleagues
course course
agency training programme

Number of host
agencies (projects) 4 8 1 10 3 2
using this modality

For some of the host agencies, regular cascade training has been pursued
through formal teaching programmes. For the four host agencies in Indonesia,
cascade training has been greatly enabled through the development of new
formal university courses as a result of the SIF project, as well as the inclusion of
higher education institutions among the SIF project partners. All of the
Indonesian and Vietnamese hospital partners are also ‘teaching hospitals’, which
has provided an existing structure for cascade teaching. In Cambodia, the
Physiotherapy host agency has continued to facilitate the formal certification
course developed as part of the SIF project, and has gained some funding from
an American Trust fund to support the training programme.
7.4.6 Three of the host agencies have integrated the knowledge gained from the SIF
volunteers into national training programmes, jointly funded by their
government and international agencies. These training programmes are oriented
towards sharing knowledge in the wider sector (discussed in Chapter 8) but staff
of the host agency also attended the sessions and this has been an important
route to cascade training within these host agencies.
7.4.7 Two projects (both in Cambodia) are not recorded in the bar chart above as
having facilitated substantial cascade
training, although both have facilitated “I shared my knowledge with my
colleagues during technical meeting
some training. The Paediatric Intensive session, but for only 20 minutes… My
Care host agency has facilitated one fairly knowledge from the training was
large training session for new staff and still limited, and I could not answer
some questions raised by the group.”
students, but has not yet developed a
(Trainee from a partner NGO in the
more regular training programme. With Speech Therapy project, Cambodia)
regard to the Speech Therapy project, the
host agency (the NGO that coordinated with the SIF to facilitate the project) has
provided some training based on the teaching modules developed by the SIF
volunteers. Yet most of the other NGO partners in this project have not
facilitated substantial training for other staff: Most of the trainees explained that
they provided a short feedback session for their colleagues, but had found it
77
 difficult because they had not fully understood what they had been taught and
did not feel confident in their teaching abilities. This highlights that teaching
skills and confidence can be a challenge for cascade training.
7.4.8 Similar to the Speech Therapy project, very few of the trainees in Physiotherapy
project (which also engaged a wide set of different NGOs) provided cascade
training within their own organisations, although some of the physiotherapy
trainees now facilitate the formal certification course which was developed as a
result of the project. Overall, the two projects that involved a wide set of NGOs
facilitated less ‘internal’ cascade training than the projects which focused on one
public hospital. This may be because this project model places the onus for
training on each individual trainee (rather than just a core group of more highly
skilled trainees, as in the public hospital projects).

Teaching skills

7.4.9 As noted above, one challenge in the facilitation of cascade training was a lack of
teaching skills, experience and confidence, as noted by 13% of trainees.
7.4.10 Yet 14% of trainees (from four of the host agencies) felt that they have gained
enhanced teaching skills as a result of their participation in the SIF project. This
includes skills for curriculum development, student assessment, lecturing and
preparing power-point slides. Several respondents from the Otolaryngology
project explained that they now have stronger skills for student interaction, as a
result of the SIF project. When speaking of their experience of teaching others,
many respondents reported feeling proud, excited, satisfied, pleased and happy.
The experience gave many trainees an opportunity to improve their own
knowledge, as well as sharing with others. As a result of the SIF project, 23% of
trainees said that they are now more confident and willing to teach others.
7.4.11 Many of the respondents who perceive
“The staff [of the host agency] were
that their teaching skills were enhanced not professional in their teaching.
as a result of the SIF project are medical They haven’t reached the level of a
university lecturers, staff at teaching trainer who knows about many
issues and is able to make the
hospitals (particularly the Otolaryngology
lecture more interesting. They did
host agency), or trainees that facilitated not train others in a systematic
the formal Physiotherapy certification manner because that is not their
course. This suggests that teaching skills profession.” (Manager, a project in
Vietnam)
were most successfully enhanced among
people who already had a good level of “I learnt a lot from the SIF
teaching experience, and those who used [volunteers] on how to build a lesson
and presentation, I am more
the skills in formal teaching programmes. confident now when presenting a
The volunteers for the Otolaryngology problem and teaching. Now I
frequently train learners at the
78 hospital.” (Doctor, Otolaryngology
project, Vietnam)
 and Physiotherapy projects also included sessions on teaching skills, which were
not provided in the other SIF projects. This perhaps suggests that dedicated
sessions on ‘teaching skills’ would enhance the quality of cascade training and
therefore broaden the impacts of the SIF projects.
7.4.12 Some respondents also noted a new importance given to training by host agency
managers. As noted in section 7.2, since the SIF projects closed, most of the host
agencies have gained additional funding to implement cascade training and to
run the new teaching courses which were developed as a result of the SIF
project. Several nurses from the Cardiac Nursing project also perceived that
since the SIF project, their managers are far more committed to training for
nurses, and “have even sent some nurses on training overseas. Awareness of the
role of nurses has changed among the leaders, to the nurses themselves”. This
example indicates managerial commitment to learning and progress. All the host
agencies had some staff receive additional training since the SIF project closed.
7.4.13 In ten of the host agencies, since the SIF projects closed, the managers and staff
have translated or developed training manuals to support the process of
teaching. For example, two managers in the Traumatology host agency have
developed detailed manuals on basic and advanced life support; and the Cardiac
Nursing host agency has developed formal guidelines and translated a large
number of guidance leaflets into Vietnamese. While it cannot be said that these
manuals illustrate a ‘new commitment’ to teaching as a result of the SIF project,
these examples certainly highlight commitment to sustaining the teaching
initiated by the project and to developing the learning environment.

79
 Box 2: Perceptions of cascade training

As illustrated in the table below, in most projects a small group of host agency staff (the core team) were selected as
‘trainers’ (30% of respondents), all of whom facilitated some cascade training after the SIF project closed. Yet a
significant number of staff who were not selected as trainers also provided some training (79% of respondents
overall). Across projects, the largest number of trainings was facilitated for staff of the department (67%), yet 40%
of respondents also trained people from external organisations.

Table 9: Cascade training facilitation

Responses to Did you facilitate
Were you trained
questions on training for Who did you train?
as a trainer?
cascade training others?
(survey respondents Staff of Staff of
Not Staff from other
- trainees in the SIF Yes No Yes No own another
sure organisations
projects) department department
Indonesia (n=24) 75% 21% 4% 100% 0 92% 21% 58%
Vietnam (n=32) 18% 82% 0 59% 41% 44% 9% 26%
Cambodia (n=34) 9% 56% 34% 94% 6% 69% 47% 38%
TOTAL (n=90) 30% 57% 12% 79% 21% 67% 26% 40%

Table 10: Trainers’ experiences of cascade training

A large number of trainees (41%) felt that facilitating training for others was a rewarding experience, which brought
pride, happiness and satisfaction; and also helped to reinforce their knowledge and teaching skills. Yet some
respondents highlighted challenges in the process of training and its quality. In some cases, host agency staff did not
have access to the teaching aids that the SIF volunteers had used, or the equipment left by the SIF volunteers for the
purposes of training had been transferred for daily use in the hospital. Other challenges included a lack of receptivity
among participants (particularly older people), varied learning abilities in the class, or a lack teaching skills.

Negative mindset Large difference in

Weak teaching Lack of teaching aids
Challenges of cascade of trainees (not learning
skills and or materials for
training for the trainers receptive; too old capacities within
experience clinical training
to change) the class
Percentage of trainees who
noted the challenge 13% 12% 13% 10%

Positive outcomes of
The experience was It reinforced forced the An opportunity to develop
cascade training for the
rewarding trainers knowledge teaching skills
trainers
Percentage of trainees who
noted the positive outcome 41% 12% 14%

80
 7.5 Impacts on service delivery and outcomes for patients

7.5.1 This component of organisational capacity focuses on results – the ultimate

impact of capacity development. As with the other components of organisational
capacity development, the SIF projects have contributed to various
improvements in service delivery and subsequent positive outcomes for patients.

Figure 7: Changes to service delivery and outcomes for patients after the SIF training

12 12

More successful treatment of

patients
10
New health services provided
8
8
7
Faster patient recovery
6
6
5 5 Reduced complications and
4 infections
4
Reduced mortality in the
department
2
Quicker response times in
emergencies
0
Number of projects in which different types of impacts on
patients were recorded (by HA) 12 projects in total

7.5.2 From the perspectives of host agency staff, all 12 projects have made positive
contributions to the host agencies’ capacities to provide more effective health
care services, such as more accurate diagnosis, more effective treatment and
improved patient care.
7.5.3 Eight of the SIF projects have led to the provision of new health services. This
includes new services for occupational dermatology (Indonesia), psychosocial
palliative care (Vietnam), speech therapy (Cambodia), a new ambulance service
(developed as part of the Traumatology project in Indonesia), and various forms
of surgery that were not previously available.
7.5.4 Host agency staff explained that this has resulted in an extension of available
services and more comprehensive patient care. For example, many trainees in
the Physiotherapy project (Cambodia) explained that, contrasting with their
previous use of ‘general massage’ for all patients, their services have expanded
into detailed diagnosis and a wide set of specialised treatments for different
81
 conditions. All the respondents from this project explained that their treatment
is more effective: success rates are hugely improved (90% of trainees) and
patient recovery is much quicker (60% of respondents).
7.5.5 Faster patient recovery was noted as an outcome of the SIF projects by 23%
respondents, from seven of the 12 projects. This is largely an outcome of more
successful treatment and reduced complications. The staff of some host agencies
explained that faster patient recovery has significantly reduced the average
hospitalisation periods for particular procedures. For the Reconstructive Surgery
host agency, shorter hospitalisation periods have been influenced by the new
practice of multi-disciplinary teams performing different procedures within one
surgery, reducing the number of operations patients have to undergo. In this
host agency, departmental records show that average patient recovery times and
length of stay have been reduced for both microsurgery and the burns unit, over
the two-year duration of the SIF project.
7.5.6 Faster recovery times are partly related to reduced complications and infections
after surgery (in five of the host agencies). For example, some respondents from
the Traumatology project (Indonesia) “There were many changes after the SIF
explained that, due to greater project… We now have better infection
attention to infection control and the control. Of 500-600 patients who had open
heart surgery, no patient has had clavicular
setting up of an infection control unit
infections. This hasn’t happened in any other
in the department, fewer patients heart institute. Clavicular infections are very
now get infections and those who do dangerous and can sometimes lead to death”
can be treated and recover more (Manager, Cardiac Nursing project, Vietnam)
quickly. A respondent from this host
“Before the training, few doctors in
agency perceived that this has helped Indonesia could do craniofacial surgery or
to increase patient satisfaction. micro surgery such as the reattachment of
veins, tissues and fingers. But the need was
7.5.7 Respondents from all five host
great because of the large number of road
agencies that provide emergency accidents. … Now micro surgery is
medical treatment explained that they undertaken almost every week and the
now have faster response times when success rate has increased a lot.” (Doctor,
Reconstructive Surgery project, Indonesia)
dealing with emergencies. They
explained that this outcome is the
result of more cohesive teamwork and
communication, as well as the systems that were set up as a result of the SIF
project – such as preparation of emergency surgery trollies and organised
placement of equipment and supplies. One of the host agencies, Traumatology
(Indonesia), was able to provide data that highlights reductions in emergency
response times. This includes statistics relating to the period after the SIF project
which highlight continued improvement.

82
7.5.8 For four of the host agencies, faster response times and more effective
emergency medical treatment, influenced by the SIF project, have led to reduced
mortality rates in the hospital:
 At the National Paediatric Hospital in Cambodia, published statistics show
that “mortality in the first 24 hours” fell from 57% in 2004 to 30% in 2006.
The managers of the host agency explained that this change was influenced
by the SIF project in the Paediatric Emergency department (2004-07), since
the department deals with patients for the first 24-hours after admission.
Overall mortality in the hospital also fell from 1.6% in 2003 to 1% in 2007.
 The Paediatric Intensive Care SIF project, also in the National Paediatric
Hospital in Cambodia, was facilitated from 2008-11. The manager of this
department explained that mortality rates in the Intensive Care Unit have
dropped from 60% (in 2007, when the unit was opened) to the present rate
of “less than 40%”, and attributed this as an outcome of the SIF project.
Within the hospital as a whole, mortality rates have fallen from 1% in 2007 to
0.7% in 2011.
 Respondents from the Traumatology host agency (Indonesia) quoted a
Master’s thesis (Headar 2000) which
found that morbidity and mortality “The change shows in the
rates in the department had fallen due satisfaction of patients when they
to the introduction of triage (exact stay here. I’ve noticed that
before, 5-7 patients come here
figures were not quoted) which
every month to complain, saying
prioritises patients with more critical ‘this person spoke to us,
conditions. approached us and acted in a
certain way.’ But until now, after
 Hospital data shows that the mortality the SIF project, there are hardly
rate in the burns unit of the any complaints.” (Manager,
Reconstructive Surgery host agency Psychosocial skills in Palliative
Care project, Vietnam)
was reduced over the two years of the
SIF project (figures were not given).
7.5.9 In four of the host agencies, successful outcomes for patients have been
illustrated by patient satisfaction and fewer complaints. Most of the respondents
related fewer patient complaints to the soft skills developed as a result of the SIF
projects – enhanced communications with patients, softer interactions and
greater attention to medical ethics, such as gaining patient consent.
7.5.10 Respondents from the four projects in Indonesia explained that the SIF projects
have helped to enhance poor people’s access to the health services they provide.
One example from the Traumatology project is the way that the new triage
system has helped to transform the previous system for patient management
83
 (which prioritised those who can pay) into a system whereby patients are
prioritised based on the urgency of their medical situation. The Traumatology
project also supported the introduction of the first ambulance service in Malang,
which has enhanced patient access to emergency care. Another example, from
the Occupational Dermatology project, is the development of factory-based
clinics and a new government policy that grants factory workers rights to free
skin tests (both of which were supported by the SIF volunteers). Both the
Traumatology and Occupational Dermatology projects also influenced public
awareness-raising campaigns (largely implemented after the SIF project closed),
which have helped to increase demand for services.
7.5.11 Some respondents took their explanation of the impacts of the SIF projects a
step further, to talk about how more effective treatment has impacted on
patients’ lives. For example, some “The volunteers also taught us enhanced
trainees from the Reconstructive techniques for head and neck surgery.
Surgery project (Indonesia) explained For patients with angina cancer, we
that faster recovery rates and shorter used to cut the whole throat and
patients could no longer speak. Now if
hospitalisation periods have reduced the the patient’s illness is discovered early,
cost of treatment for patients, and that we can save the angina and patients can
more successful surgery (such as re- still speak.” (Doctor, Otolaryngology
attachment of fingers and project, Vietnam)
reconstruction of ears) has improved their patients’ quality of life and self-
confidence. Some respondents from the Occupational Dermatology host agency
(Indonesia) similarly explained that their more successful identification and
treatment of skin diseases, and advice on prevention, has reduced absence from
work (and thus loss of earnings) in several of the factories in which they have set
up clinics. At the Palliative Care host agency (Vietnam), the new approaches to
pain management (particularly the use of oral morphine) and psychological care
have helped to significantly ease patients’ pain, according to many respondents
from this project, which has helped to enhance the patients’ quality of life in
their last few years.

7.6 Sustainability of organisational change

7.6.1 The large majority of respondents (90%) explained that the SIF projects had led
to lasting impacts in their department of organisation. Most of them attributed
this to the development of formal guidelines and standard operational plans, or
new patient assessment forms, which have helped to institutionalise changed
systems and work processes. Some respondents also explained that sustained
impacts in their organisations have been created through the development of
new norms in their organization, such as a new learning environment, stronger
teamwork or greater communication with patients.
84
7.6.2 A small number of respondents (10%) did not feel that changes had been
sustained in their organisations. Many of these respondents were from the two
projects that involved individuals from several different NGOs/hospitals. In these
projects, some respondents noted that changes had not been institutionalised,
partly because there was a lack of acceptance or understanding from other staff.

7.7 Unexpected impacts of the SIF projects

7.7.1 Some of the changes explained in this chapter were described as ‘unexpected
impacts’ of the SIF projects, which is interesting to re-emphasise here.
Particularly in the Cambodian and Vietnamese host agencies, one impact often
explained as ‘unexpected’ was the promotion of trainees (particularly people
from the ‘core team’ of trainers) into managerial positions. This has in turn
increased their ability to share their knowledge with other staff.
7.7.2 Another unexpected impact in the Cambodian and Vietnamese host agencies has
been greater motivation to learn among staff, and a new managerial
commitment to provide training for staff, particularly for nurses.
7.7.3 Among respondents from the Indonesian projects, an unexpected impact has
been greater national recognition of the host agencies, in some cases including
accreditation and awards. Greater recognition was also noted as an unexpected
impact by some respondents in the two Palliative Care projects in Vietnam – in
this case greater recognition of the department within the hospital. One
manager explained that this recognition has increased staff motivation: “Staff
used to cry and ask to leave when they were assigned to this department. But
now hardly anyone wants to leave. We have prestige in the hospital now and we
are asked to do trainings for others.”

85
 CHAPTER 8: Outcomes in the wider profession and sector
The SIF aims to influence the wider profession and sector through its Specialist Team
projects, and this is formally incorporated into the project design. The two most common
routes to promoting wider influence are the Training of Trainers (TOT) programme (an
element of all projects), and development of tertiary education teaching courses. Through
this, the SIF projects aimed to influence the wider sector through skill-sharing with peers,
residents and students. As we explain in this chapter, some of the projects also influenced
other types of (often unexpected) benefits in the wider sector – such as policy change. The
analysis of wider influences in this chapter makes a distinction between vertical and
horizontal impacts:

(a) Horizontal impacts influence individuals and organisations beyond the host agency
(b) Vertical impacts are influences at a higher level that affect the sector at large.

The ‘influences on the wider sector’ analysed in this chapter were all highlighted by host
agency staff, in discussion on the impacts of the SIF projects. Yet it is important to note that, while
the SIF project was a building block and source of inspiration for these wider influences; it was just
one contributing factor among many others.

8.1 Horizontal impacts

Figure 8: Changes to other organisations beyond the host agency

12
Trainings provided for staff of other
hospitals & NGOs
10

Presentations at conferences and

journal publications
8

Use and sharing of the skills in

6 voluntary work, disaster relief and
private practices

Community outreach: Public

4 education & promoting demand for
services

2 Movement of trained Residents/

students to other hospitals

0 New system of referrals or

Number of SIF projects in which different types of horizontal impact ambulances that links hospitals
were gained (12 projects in total)

86
8.1.1 Sharing skills with peers and organisations beyond the host agency.
8.1.2 Eleven of the host agencies provided training for staff of other organisations, to
share the knowledge and skills they had gained as a result of the SIF project. This
skill-sharing has been achieved through various approaches.
8.1.3 In the eight host agencies that are teaching hospitals (in Indonesia and Vietnam),
skill-sharing with other organisations has been achieved partly through the
existing system of learning placements for staff of other organisations and
students. For example, the Palliative Care and Otolaryngology host agencies
(both in Vietnam) have shared the skills they gained from the SIF volunteers with
nurses and Resident doctors on learning placements in their organisations. The
Traumatology/Emergency Nursing host agency (Indonesia) has also received a
large number of staff from other hospitals on learning placements, to teach the
system of triage and emergency medicine now used at the hospital. This has
been influenced by the central government’s recognition of emergency medicine
system at the hospital as the ‘model’ to replicate (see section 8.2). A process of
skill-sharing beyond the host agency has also been achieved by the movement of
trained Residents to other hospitals after their Residency ended, in five of the
host agencies.
8.1.4 Skill-sharing with other organisations has also been achieved outside of formal
teaching programmes, through workshops for networks of professionals – an
approach used particularly in the Indonesian projects. For example, since the SIF
project closed, the Occupational Dermatology host agency (Indonesia) has
facilitated a series of ten training trainings (each with 40-60 participants) for
doctors of healthcare centres, private companies in the local area and lecturers
from six medical universities. The Reconstructive Surgery host agency (Indonesia)
has similarly facilitated six workshops and six seminars for medical professionals
and university lecturers. Since the SIF project closed, they have trained over 200
health care professionals, including 30% of reconstructive surgeons in Indonesia.
Table 11: Cascade training – estimated number trained
SIF project Traumatology Palliative Otolaryngology Paediatric Reconstructive Speech
Care (ENT) Emergency Surgery Therapy
Estimated >10,000 >1,000 >1,000 700 >200 70
number (since 2003, (since 2007) (since 2007) (since 2007) (Since 2009) (since 2009)
trained incl public first
aid training)
SIF project Physiotherapy Emergency Psychosocial Cardiac Paediatric ICU
Nursing Skills in Nursing
Palliative Care
Estimated 600 >500 300 >300 200
number (since 2010) (since 2010) (since 2010) (since 2011) (since 2011)
trained

87
8.1.5 Table 11 summarises the estimated number of people who were trained by the
host agency staff, in skills that were gained as a result of the SIF project.
8.1.6 A fairly large number of respondents (28%) explained that they have used and
shared the skills and knowledge in the other organisations and contexts in which
they work. This includes work in private clinics and voluntary work (such as a
Cleft Lip NGO in Indonesia), as well as participation in national disaster relief
work in Indonesia. Several trainees from the Emergency medicine projects in
Indonesia explained that, while on national disaster relief work, they have shared
some of the skills they learnt from the SIF volunteers with their peers on the
mission, and introduced the principles of triage and team work. Several
respondents from Cambodia also noted that their use of the new skills in their
private sector work has enhanced client satisfaction and their own self-
confidence, as well as their earning potential.

Impacts on the wider sector through broadened referral systems

8.1.7 Two of the host agencies, both in Indonesia, have impacted on the wider sector
through their formal linkages to other hospitals. The Traumatology project
included guidance and encouragement to set up a formal referral system with
other hospitals in the area. This referral system is partly facilitated through the
new ambulance system, developed as a result of the SIF project, which is
overseen by the District Health Department. The Reconstructive Surgery host
agency has also developed additional referral networks due to the new services
and techniques now offered as a result of the SIF project. Host agency staff
explained that these referral networks help to broaden the impacts of the skills
gained through the SIF projects into a wider set of localities.

Public education and community outreach

8.1.8 Although the SIF Specialist Team volunteers do not generally work with
communities, or aim to influence demand for services, four of the host agencies
in this evaluation have achieved such outcomes, and the trainees explained that
this was influenced by the SIF project. All four of these host agencies are in
Indonesia, perhaps suggesting that funding for community outreach is more
available in this country context.
8.1.9 One of the aims of the Traumatology project (Indonesia) was to improve the
wider context of emergency service provision – by supporting development of
pre-hospital care, including a new ambulance service. The SIF provided funds for
three ambulances to be refurbished and donated, and the volunteers supported
the technical design of the ambulance service, training for paramedics and liaison
with government health department staff. The volunteers also promoted host

88
 agency attention to the role of communities in pre-hospital care, and encouraged
the host agency to facilitate training on basic resuscitation and first aid for
community groups and the local police force.
8.1.10 Staff of the Traumatology and Emergency Nursing host agencies provided basic
resuscitation and first aid training to a nurses, Red Cross Youth and police all over
Indonesia. The trainings commenced after the SIF project was closed, and
therefore are an indication that the project fostered momentum for change that
was sustained beyond the project. Over the ten years since the project closed,
the host agency staff directly trained more than 10,000 police, citizens, youth
and community leaders on basic first aid, CPR and use of emergency services.
They have also used radio, television and posters to raise awareness about first
aid and the need to bring accident victims to hospital, including use of the new
ambulance service. The hospital has also influenced greater traffic-police
monitoring of seat-belts and safety helmets. Although the impacts of this work
cannot be directly quantified in this evaluation, it is notable that the department
now receives considerably more patients (Headar 2010). This may indicate that a
greater number of accident victims are now reaching hospital.
8.1.11 The Occupational Dermatology project (Indonesia) intended to influence public
awareness and prevention of skin diseases, through promoting public education,
understanding of prevention in workplaces, collation of statistics on risk factors
and introduction of new legislation on occupational skin diseases (discussed in
the next section). Trainees from this host agency explained that, since the project
closed, they have facilitated various public education seminars on skin diseases
in collaboration with the District Government. Collaboration with government
has been a challenge, however, partly due to the frequent rotation of senior civil
servants. The host agency has also continued to facilitate education on
prevention, diagnosis and treatment at two factory clinics that were initiated as
part of the SIF project. However, most of the factory clinics have now ceased,
due to a lack of cooperation from factory managers, and the host agency and its
staff identified limited resources and time as challenges for sustaining their work
in factory clinics.
8.1.12 The Reconstructive Surgery host agency (Indonesia) has also facilitated public
education and training on the prevention and treatment of burns; some of the
trainees in the Speech Therapy project (Cambodia) have facilitated community
outreach education for families on how to support children with disabilities.

8.2 Vertical impacts

8.2.1 Some of the SIF projects have achieved ‘vertical impacts’: national level
initiatives and changes that hold potential to affect the sector at large.

89
Figure 9: Changes at the national level

12 Presentations of knowledge to
national professional associations

10
Influenced policy change or new
guidelines at regional or national
8 level
Integration of knowedge gained
from SIF project into national
6 trainings
Development of new tertiary
4 education/ Professional
Certification programmes
Integration of knowledge gained
2
from SIF project into existing
tertiary education courses
0 National government has
Number of SIF projects in which different types of vertical promoted the new system as a
impacts were gained (12 projects in total) ‘model to replicate’

Vertical impacts: New national policies and guidelines

8.2.2 One important influence over the wider sector is national policy. Five of the SIF
projects have led to changes in national or regional policy, legislation or
guidelines.
8.2.3 One objective of the Occupational Dermatology project (Indonesia) was to
influence the creation of new legislation on occupational skin diseases. The
volunteers supported the host agency to pursue advocacy and provide technical
advice to the government. This has led to the creation of new legislation (at the
regional level) that grants workers’ rights to free consultations with
dermatologists and skin patch tests, including the right to take absence from
work for these medical consultations. Similar legislation is now being drafted at
the national level. According to host agency staff, this legislation has had a
positive impact on the number of factory workers who now come for
consultations on skin diseases.
8.2.4 The lead volunteer for the Palliative Care project (Vietnam) also pursued
advocacy to promote change to legislation and increased national supply of
required medicines, in collaboration with the host agency management and
some professors from the Harvard Group (who also support the development of
palliative care in Vietnam). A key challenge for the host agency and wider sector
was restrictive legislation governing the use of oral morphine (an important
medication for pain management) including a prescription limit of ‘seven-day
90
 supply’ and a limit on the total prescription volume. The seven-day supply rule
was particularly a problem for patients from outside of the city, who could not
travel back to the hospital for repeat prescriptions. Influenced by the advocacy,
the legislation has now been changed to allow a 30-day supply.
8.2.5 Another advocacy initiative pursued by this host agency, with the support of the
SIF volunteers, has been increased production of oral morphine in Vietnam.
Although there is a factory in Vietnam which produces oral morphine, it was
being produced in limited quantities and not on a regular basis. As a result,
hospitals often had no supply and could not plan for the use of this medicine.
The volunteers encouraged the host agency to lobby the local factory to increase
its production and regular supply of oral morphine to all hospitals in Vietnam.
The host agency engaged other hospitals in the advocacy, through a survey on
their required supply of oral morphine. Over time, and with challenges along the
way, the staff of this host agency explained that the lobbying has led to a regular
supply of oral morphine in the hospital (and wider Vietnam). This was noted as
one of the most significant outcomes of the SIF project.
8.2.6 The Palliative Care host agency has also contributed to new national guidelines
on cancer care and prevention. In 2011, after the completion of the SIF projects,
the host agency played a leading role in preparing the component on palliative
care, using the knowledge gained from the SIF volunteers.
8.2.7 Another significant change, influenced by the Traumatology and Emergency
Nursing projects in Indonesia, has been new regional government guidelines on
treatment ethics in hospital emergency departments. As one doctor put it:
“Many of the patients are poor. After the SIF training, the Malang Trauma Team
suggested to the governor that we should provide emergency care to all, and not
ask for patient ID and ability to pay before treating them. This is now the
standard system. Provincial government ordered all hospitals that emergency
patient must be helped first in emergency department regardless of ability to
pay. The motto is Live Saving Is First. This was a new treatment ethic which we at
Malang influenced.”
8.2.8 A significant factor that contributed to these changes in government legislation
and guidelines has been the sphere of influence of the host agency in
government domains. For example, in Vietnam, the Palliative Care host agency
has been able to influence government because the managers of central
hospitals in Hanoi (where the central government is located) have strong links to
senior government officials. Also in Vietnam, the linkage between the volunteers
and the Harvard Group has also been a contributing factor, since the Harvard
Group has built a strong relationship with government over time. The influence
of the Occupational Dermatology and Emergency Medicine host agencies has

91
 been bolstered by their new position as national centres for their specialisation –
recognition which was influenced by the SIF project.

Vertical impacts: Replication of models

8.2.9 The new system of triage and emergency medicine at Saiful Anwar Hospital in
Indonesia has been formally recognised by central government and is now
promoted as a model to replicate. As mentioned earlier in the report, these new
systems were developed with support from SIF volunteers as part of the
Traumatology project. Host agency managers explained that this recognition has
been influenced by the international ISO certification given, in 2003, to the
Emergency Department Standard Operational Plan (SOP) and formal
commendation from the USAID in 2004.
8.2.10 At the regional level, a respondent from the traumatology project also noted that
the model used for the SIF’s cooperation with the RSSA hospital has been taken
up at the East Java level, at the regional government. This model has made it
easier for health care providers to gain government approval for collaborations
with international agencies.

Vertical impacts: National-level teaching and training programmes

8.2.11 Three of the host agencies have developed new formal tertiary education
programmes as a result of the SIF project: Traumatology, Emergency Nursing and
Occupational Dermatology. All three of these host agencies are in Indonesia, and
each of the projects included one or two higher education institutions as a
partner. Each of these tertiary education courses are the first of their kind in
Indonesia and thus have potential to greatly impact on the wider profession and
sector. There have been challenges with the development of these courses,
however. The Emergency Nursing course has now run for two years, yet it has
not yet gained formal certification status from the central government. In the
Traumatology project, other departments in the university and hospital did not
initially support the Master’s course in Emergency Medicine. This was because
the course included training and placements for emergency department doctors
in other specialisations and departments (such as emergency heart surgery); and
other departments felt that this infringed on their territory. The course is now
running, although cooperation remains an issue for wider systems integration.
8.2.12 An additional two of the host agencies have integrated the skills and knowledge
gained from the SIF project into existing tertiary education courses:
Reconstructive Surgery (Indonesia) and Otolaryngology (Vietnam). Both of these
host agencies are teaching hospitals and national centres for their specialisation,
and so influential over learning in the sector.

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8.2.13 Another route to vertical impacts is national training programmes. For four of
the SIF projects, the knowledge gained from the SIF volunteers has been
integrated into national training programmes, which are jointly funded by their
government and international agencies. For example, in Vietnam, a National
Cancer Care programme was launched in 2011. The Palliative Care host agency is
leading the palliative care component of this programme and has based the
teaching modules on the knowledge gained as a result of the two SIF Palliative
Care projects. The Paediatric Emergency host agency has also integrated the SIF
volunteer teaching modules into the WHO ETAT training programme, which has
been facilitated both for host agency staff and external organisations. These
national programmes have enabled cascade training by providing a structure and
funding. The WHO ETAT funding has now ended, however, and no trainings are
now taking place. In Cambodia, one challenge of facilitating cascade training is
the participants’ expectation that they will receive a fairly large per diem
(perhaps influenced by the practices of international organisations in Cambodia).
8.2.14 The Physiotherapy host agency (Cambodia) has also continued to facilitate the
formal course that was developed through the SIF project: the Advanced
Certificate in Physiotherapy Practice (ACPP). This course is open to all
physiotherapists in Cambodia. The Physiotherapy host agency has gained some
funding from an American trust fund to financially support the facilitation of the
course, yet physiotherapists (or their organisations) also pay course fees. This
willingness to pay for training contrasts with the challenge of having to pay per
diems to training participants in Cambodia (as noted by staff of Paediatric
Emergency host agency). A volunteer for the Physiotherapy project explained
that willingness to pay for training is due to the potential for physiotherapists to
gain additional income from private work. For people whose course fees are
paid by their organisations, this contrast may also be shaped by the international
funding which supports most of the physiotherapy NGOs in the evaluation.
8.2.15 Managers from seven of the host agencies have presented the knowledge gained
from the SIF volunteers at national professional conferences. Such sharing has
been most substantially achieved by the Occupational Dermatology host agency
in Indonesia. Its managers introduced occupational dermatology as a theme at
the National Dermatology Association Annual Scientific Meeting in 2007, and
they have since presented research (undertaken at the factory clinics) at national
and regional dermatology conferences and in various professional journals. This
host agency also facilitated a workshop at a national professional association
‘symposium’ – covering a large percentage of dermatologists in Indonesia.

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 CHAPTER 9: Success factors and challenges for capacity development
The outcome of each SIF Specialist Team project is clearly impacted by what it set out to
achieve, as well as the project design, approaches used and contextual issues. The
discussion in the previous chapters has outlined various success factors and challenges in
relation to particular themes. This section presents a summary of the factors that
contribute to successful outcomes and some common challenges that were reported. This
analysis is divided into three sections: (a) volunteer training methods; (b) the influence of
host agency and country contexts; and (c) SIF project design and oversight.

9.1 Volunteer training methods

Table 12 summarises the most useful training methods utilised by the SIF volunteers, from
the perspectives of host agency staff.

Table 12: Most useful training methods (Survey results n=90)

Most useful method

Volunteer training methods (% of survey
respondents)
Classroom training (including group discussion & practical sessions) 37%
Developing training materials or manuals 19%
Reviewing and guiding communication with patients 17%
Advice on work processes and systems 10%
Guidance in work with patients in the ward, surgery or clinic 10%
Advice on leadership, planning or team work 8%
Attachment in Singapore 8%
Training on use of equipment 6%
Review of guidelines or policies and provision of advice or guidance 4%
Donation of supplies or equipment 3%

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9.1.1 As illustrated in Table 12, host agency staff perceived that the most useful
teaching methods used by the SIF volunteers were classroom-style lectures
(supported by training materials) and various forms of practical ‘on-the-job’
training. The most common comment from the trainees was that a combination
of different methods made the training effective. For example, many trainees
felt that they came to really understand the theory they were taught in
classroom lectures when the volunteers provided practical guidance on the new
techniques, through joint work with patients. Some participants also felt that
such practical guidance was easier to remember and apply, compared to
lectures, and enabled clarifications that may not have been discussed in the
classroom. Many respondents also appreciated the use of group discussions, role
play, ‘patient-case presentations’ and question and answer sessions, suggesting a
preference for interactive teaching instead of one-way lecturing.
9.1.2 Only a small number of respondents had the opportunity to participate in the
training attachment in Singapore. Yet for these people, the attachment was
often noted as one of the most useful elements of the skill-sharing project. For
some, witnessing the methods and technology used in Singapore was motivating
and inspirational, and being able to compare the two countries helped to raise
their level of awareness and created deeper understanding of the knowledge
they received.

Language and translations

9.1.3 All volunteers facilitated their trainings in English, with translation into the local
language (by a host agency staff member or a professional translator). This
enabled the sharing of skills between Singaporeans and other nationalities. Yet
language difficulties were pinpointed by trainees as the main challenge of
working with the SIF volunteers. Many trainees explained that the highly
technical nature of the trainings was sometimes difficult to translate, and the
translations were sometimes difficult to understand. Nurses in several projects
noted that they were at a particular disadvantage because, unlike doctors, they
have very weak English language skills, and there was a tendency for doctors and
volunteers to talk together in English. One suggestion was to send training
materials in advance in order to allow for better translation to take place, and
to develop a translated glossary of technical terms to support learning.

Targeting the training at the right level

9.1.4 The SIF volunteers generally pitched the training at the right level. In several
projects, the ‘difficulty level’ of the training programmes were reduced once the
volunteers gained better understanding of existing capacities in the host agency.

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 In some cases, the volunteers shifted the focus to developing general nursing and
surgery skills, as a basis for more advanced specialist skills. This responsiveness
and flexibility was important to skills development outcomes. Yet 23% of trainees
(including both nurses and doctors) felt that some of the training was too
advanced. Most of these trainees were from Cambodia (where 38% felt that the
training was too advanced), which perhaps suggests a need for greater attention
to local capacities in the design of training programmes. In some projects, the
trainees were of quite different ability and experience. When they were trained
together, this was a challenge for pitching the teaching at the right level.

Depth and scope of technical skills training

9.1.5 The SIF volunteers generally shared a well-targeted set of technical skills. As with
the difficulty level of the skills, the depth and scope of the trainings were
sometimes reduced in response to local capacities and needs. Yet in three
projects, host agency staff felt that the trainings tried to cover a large set of
topics and the trainees perceived that the knowledge was “scattered” or not
deep enough. This has been a challenge to application of the skills in practice.

Adaption of skills to the local context

9.1.6 Many of the techniques and approaches used in Singapore had to be adapted for
use in the local contexts, to take account of the existing work processes and the
available equipment and supplies. In most cases, the volunteers focused on
upgrading skills that were low-tech and manual. The volunteers also worked
with the trainees to think about how some of the skills could be integrated into
existing work processes through simple adaptations or low-cost purchases. One
example is the use of s-hooks to hang IV drips from curtain poles (instead of the
free-standing IV units used in Singapore). The process of adapting the
techniques often promoted local ownership, and many volunteers noted that the
host agency staff were very proud of their achievements.
9.1.7 Some of the skills taught by the volunteers were not easily adapted to the local
contexts. In terms of hard skills, this was often because equipment and supplies
were not available. Some of the psychology skills were particularly difficult to
adapt to the local culture; for example, adapting psycho-social skills for use in the
Vietnamese context, where doctors and patients do not usually talk openly about
emotional issues. Even when techniques had been adapted, the trainees felt
that the need to do so was a challenge of the skill-sharing process.

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 Volunteer flexibility and responsiveness to the host agency context

9.1.8 The flexibility of the volunteers is a strong factor for success. While particular
objectives are set out in the initial project proposal, the volunteers tend to use
this as a starting point and the projects take new directions as they progress. All
of the projects changed in some way as they progressed: reduced scope and
level of difficulty; changed focus from specialist skills to general nursing skills;
new attention to internal systems, etc. Thus flexible approach promotes
responsiveness to the host agency context.
9.1.9 Some trainees felt that aspects of the volunteers’ management style did not
match with their local working culture. Some incompatible styles include
excessive discipline, the speed of work and a very direct approach. In two cases,
comments from host agency staff suggest that some volunteers were quite
directive about the trainings (such as insisting on training all nurses on a piece of
equipment, although the managers felt this was not necessary and “wasteful”; or
strongly questioning staff who had not achieved tasks between volunteer visits).

Supporting host agency connections to other international organisations and

networks

9.1.10 When the volunteers helped to connect the host agencies to other international
organisations or networks, this has provided a link to new sources of knowledge
and support. For example, the lead volunteer for the Physiotherapy project in
Cambodia helped the host agency to join the World Confederation of Physical
Therapy, which has since opened up new avenues for training support and
linkages to international sources of knowledge and funding. Some of the
volunteers also linked the host agencies with universities and specialists in other
countries beyond Singapore, who have since provided training for the host
agency.

9.2 Contextual factors within the host agency

9.2.1 The analysis in this report has highlighted many aspects of the host agency
contexts that were influential over the outcomes of the projects. Some of the
most frequently mentioned success factors and challenges are outlined in this
sub-section.

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Table 13: Volunteer approaches to capacity development – success factors and challenges
Table 13 provides a detailed summary of the training approaches used by the SIF volunteers, and
highlights the success factors and challenges from the perspectives of host agency staff.
Training
Success factors Challenges
Approach
Classroom-style teaching was very Language/translation issues were a
useful for sharing new theoretical challenge for full comprehension. This
Classroom style knowledge, and also provided a group was particularly a challenge for nurses
teaching setting in which new knowledge could
(lectures and be discussed. The use of teaching aids,
workshops) videos and small-group work and were
particularly useful for skills
development.
Practical guidance helped trainees to One of the projects included only
understand the new skills how to use classroom style teaching without clinical
Practical them in practice. training. The volunteers anticipated that
guidance in Working alongside the volunteers in the core team of trainees would set up
work with practical situations helped to promote clinical teaching sessions to share skills
patients improvements in professional between volunteer visits, yet this was a
(e.g. patient behaviour. During practical sessions, challenge and rarely happened.
based teaching the volunteers also identified Some trainees from other projects felt
and joint- challenges in professional practices that there needed to be more practical
surgery) (such as hand-washing and use of sessions with patients, because they did
medicines) and were able to promote not fully understand how to apply the
alternatives. skills.
Interactive teaching methods were a Language/translation issues are a
Interactive new teaching style for many trainees, significant challenge for the flow of group
teaching and helped them to understand and discussion. Doctors sometimes used
methods retain the new knowledge and English in these sessions, which was
(e.g. group techniques. difficult for nurses because it tended to
discussions, role One particularly useful approach was shift discussion into English for some time.
play and the presentation of patient cases,
presentation of following bedside teaching or joint-
‘patient cases’) surgery. This helped to reinforce
learning by promoting discussion.
In several projects, the ‘core team’ of In some projects, the ‘core team’ of host
host agency staff co-facilitated trainings agency trainers lacked the confidence and
alongside the SIF volunteers. This skills to co-facilitate trainings alongside
Trainee co-
supported development of teaching the volunteers.
facilitation of
skills and confidence, and helped to
trainings
make the trainings locally appropriate.
It also fostered greater local ownership
of the project.
In some projects, the volunteers -
Group based
promoted team work by facilitating
teaching and
group-based trainings and encouraging
guidance on
the common use of standard terms.
team systems
This approach helped to foster team
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 cohesion and communication.
Guidance to improve team systems and
staff roles have also helped to improve
efficiency and coordination within host
agencies.
In many projects, training was provided
on equipment that existed in the host
agency. This training contributed to
Use of significant and relevant skills
equipment and development. Many projects also
specialised included guidance on updated or
supplies in advanced techniques, which required
training the use of specialist supplies that are
relatively inexpensive (such as IO
needles and special wound dressings).
Some of the teaching approaches used
by volunteers anticipated (or required)
Requirements
that trainees would research and study
to research and
between volunteer visits. Where this
study between
additional work was achieved, it helped
volunteer visits
to progress the speed and depth of
learning.
Many of the projects included a
Provision of
donation of reference materials and the
reference
provision of lecture notes and
materials
guidelines. These materials have
(manuals, text-
helped the trainees (and other staff)
books,
refresh their knowledge and continue
guidelines)
learning.
Review of Some of the volunteers reviewed
guidelines and existing guidelines and policies, and
support on helped to guide their improvement.
improvements During or shortly after the SIF project,
most of the host agencies developed
formal guidelines or protocols which
gave authority and structure to the use
of the new skills and approaches. Such
written guidance has helped to
institutionalise aspects of
organisational change.
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In several projects, equipment and
specialised supplies were taken to the
host agency for the training. When the
equipment is not available in the host
agency, these skills have not been
retained, and host agency staff felt that
the training was ‘not relevant’. This issue
was raised in relation to large technical
equipment, but also smaller items such as
particular types of breathing tube, wound
dressing & scalpels.
Many trainees found it difficult to find the
time to research and study between
volunteer visits, on top of their full-time
jobs. Some trainees also found it difficult
to access reading materials (including on-
line resources).
Not all projects included donation of
textbooks, and a lack of updated reference
materials is a challenge for skills
development in many host agencies.
Some doctors suggested that the SIF could
consider funding access to on-line medical
journals.
A lack of development of protocols or
formal guidelines on the new techniques
and systems can present a challenge for
wider application of the new skills among
staff that did not directly attend the
training. In two projects, a few of the
more senior staff have not recognised the
new skills and this has made it difficult for
the trainees to use these skills when
working under them.
 Staff motivation

9.2.2 Positive motivation among host agency staff is clearly the most important factor
that has contributed to the use of new skills and behavioural change. As
discussed above, several volunteers perceived significant change in the mindset
and motivation of host agency staff as the projects developed, which was both
an outcome of the projects in itself and a factor that underpinned other changes.
Some trainees, particularly from the Physiotherapy project, have used the new
skills in their private sector work. This opportunity to make additional income
has significantly contributed to their motivation to learn.
9.2.3 In some cases, staff motivation was initially affected by low staff salaries and
morale – and in some host agencies a feeling that new knowledge would bring
additional work without extra pay. While this challenge was overcome in most
projects, staff morale remained low in one project and this affected individual
capacity development outcomes. Morale is low in this particular project partly
because many staff did not choose to work in the new department and the work
is physically and emotionally draining; and also because staff salaries are low and
incomes are made mainly through private sector work. While this project has
some significant outcomes, including contributing to lower mortality rates in the
hospital, many respondents explained that the staff do not feel responsible for
their work and some of the new skills are not well used.
9.2.4 In some host agencies, staff experiences of cascade training highlighted that
there was a lack of willingness to learn among some of their peers (particularly
older staff, who did not want to take up new ideas).

Management commitment

9.2.5 In projects where there was strong managerial commitment and guidance, this
was a critical success factor in individual skills development. In most of the host
agencies, the managers collaborated with the volunteers to support significant
changes in their departments which have enabled skills development and
retention. This included the development of new protocols and guidelines to
institutionalise the new approaches. It also included efforts to gain funding for
new equipment, and making changes to staffing structures and systems to
support the use of the new skills.
9.2.6 In one of the host agencies, the SIF project was strongly supported by one host
agency manager, who initiated the project and is spearheading change in the
host agency and wider professional community. But another manager of the
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 host agency felt strongly that the staff should not take on the new area of work
(believing that it should be the task of a separate team). Each of the managers
has supporters in the department. While skills were developed as a result of the
SIF project and some are now used regularly, the difference of opinion in the
department has limited the full uptake of the new approaches.

Cooperation of other colleagues and departments

9.2.7 Some trainees explained that it has been difficult to use some of the skills in
practice because their colleagues, or other departments, did not cooperate. This
was particularly noted in the Physiotherapy project (by participants who work in
public hospitals) and the Traumatology project (where some other departments
have not cooperated on specialist skill-sharing or patient referrals). Some
trainees noted that they could not use the new skills, because some of their
seniors who did not attend the training did not recognise the new approaches.

Supervision and guidelines on the use of new skills

9.2.8 During or shortly after the SIF project, most of the host agencies develop formal
protocols which gave authority and structure to the use of the new skills and
approaches. Such written guidance has helped to sustain the use of the new
skills, among trainees and their wider set of colleagues.
9.2.9 Supervision and guidance on the use of new skills is a challenge in some host
agencies (particularly noted by respondents in Cambodia). Two of the
Cambodian projects engaged individuals from different NGOs/hospitals. In most
cases, just one or two staff were trained from each NGO, which has limited the
availability of support and guidance within the organisation.

Financial resources

9.2.10 A lack of equipment and resources was the most mentioned challenge that
affected the sustained use of the new skills. In some host agencies, equipment
that was available at the time of the training has now broken down and they do
not have the capacity to repair it. Only one of the projects (Traumatology) built
host agency capacity for equipment maintenance; while the volunteers for the
Paediatric ICU project raised awareness of maintenance needs and tried to
enhance links with service units of the hospital. Some trainees also noted a lack
of smaller equipment, such as airway tubes and smaller face masks of a size
more appropriate for infants.

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9.2.11 In some host agencies, there is a lack of resources to purchase consumables
needed to use the new skills. For example, the National Paediatric Hospital in
Cambodia has presently run out of IO injection needles, which cost about US$50
each. Similarly, the Reconstructive Surgery department in Indonesia has an
irregular supply of the special wound dressings used in Singapore; and the
Traumatology department in Indonesia reuses ECG patches, because supply is
inadequate.
9.2.12 Some of the host agencies (particularly in Indonesia) have gained additional
budget to purchase some equipment and supplies required to use the skills they
were taught by the SIF volunteers. And some host agencies (across countries)
have sourced additional funding to support cascade training. The ability of host
agencies to access additional funding is affected by both the country context and
the ability of host agencies to exercise influence over government bodies and
other sources of funding such as international agencies.
9.2.13 In some contexts, like Cambodia, cascade training for staff of external
organisations requires substantial funds, due to expectations that participants
receive a fairly large subsistence allowance for attendance at trainings. This can
be a challenge for the host agency.

Human resources

9.2.14 Understaffing problems were noted by 39% of respondents, as a factor which

was a challenge in the trainings and use of the new skills. Understaffing is a
challenge particularly in hospitals in Vietnam and Cambodia. In Vietnam, two of
the hospitals found it difficult to release staff for training due to understaffing in
the department. In both Vietnam and Cambodia, there was also a challenge of
staff of the public sector hospitals still ‘on-duty’ while attending the trainings,
being too tired to concentrate during the trainings because they had just worked
a nightshift, or trainees leaving the trainings early to go to their private practices.
Many volunteers made efforts to work around these challenges. For example, In
the Cardiac Nursing project in Vietnam, the volunteers repeated the same
training in the morning and afternoon ‒ to enable more nurses to attend.
Innovatively, they developed this into a model for ‘training of trainers’: the core
trainers attended the morning sessions, then also helped to teach the afternoon
session. Volunteers in most public hospital projects in Cambodia and Vietnam
also adjusted training times to enable staff to go to their private practices.

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9.2.15 Particularly in the projects that focused on psychology skills, understaffing in the
host agencies also presented a challenge in the use of the skills, due to the short
time that can be spent with each patient.
9.2.16 In several of the host agencies, the movement of staff to other departments (or
to other organisations) has been a challenge for the sustainability of capacity
development. While respondents explained that new team members are
provided with training, some felt that this was not as effective as the skill-sharing
provided by the SIF volunteers.
9.2.17 Some host agencies have many staff with good teaching skills and experience
(particularly staff of teaching hospitals and university lecturers). This enables
good quality cascade training. Other host agencies have few staff with the skills
and experience required to teach others effectively. This is a challenge for
cascade training and thus building capacity beyond those who directly attended
the SIF training.

Patients and their families (Culture, finances, beliefs)

9.2.18 Trainees from several projects explained that their use of the new skills is
dependent on patients. For example, the approaches to speech therapy and
physiotherapy taught by the volunteers include training the patients and their
caregivers to do the exercises at home. However, many trainees found that many
patients/parents do not have the required commitment and understanding to do
these home-exercises.
9.2.19 Another challenge (commonly mentioned in Cambodia and Vietnam) is that
many patients do not have the money to pay for treatment. This problem was
less noted in Indonesia, where the health insurance scheme for the poor has
perhaps been more widely taken up and used (although some host agency
managers did explain that the local governments are currently struggling to
reimburse hospitals for the cost of treatment given to insured patients).

Government support

9.2.20 In some host agencies, the use of the new skills was enabled by policy changes.
For example, in Vietnam the lead volunteer and host agency successfully
advocated for government intervention to promote the supply of oral morphine.
Now that the host agency has a more regular supply of oral morphine, the staff
are able to apply their new knowledge on the use of oral morphine, developed as
a result of the SIF project. Similarly, in Indonesia, the volunteers supported the
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 host agency to advocate for a new policy which grants factory staff rights to free
skin disease tests. Because of this, there is more demand for occupational
dermatology services, and it has enabled the host agency staff to use and retain
the skills they developed as a result of the SIF project.

Connections and influence

9.2.21 Successful advocacy for changes in policy or legislation require connections and
influence, alongside a well justified case for change. The host agencies which
achieved changes to policy and legislation, with the support of the SIF volunteers,
each had a level of influence in government circles. For two of the host agencies,
this influence may have been bolstered by the new national recognition that the
host agencies gained as national centres for their specialisation, which was partly
an outcome of the SIF project.

9.3 Project design and oversight by the SIF

This section provides an analysis of the success factors and challenges of the
project design.

9.3.1 Engagement of host agency management in the design and management of

projects
9.3.2 Nine of the 12 projects in this evaluation were initiated by the host agency, i.e.
the projects were demand-driven. In most cases, this has helped to ensure
strong managerial support for the projects. Good managerial support was also
generated in the projects that were initiated by the SIF. In general, relationships
with host agency management were built through the lengthy period of pre-
project planning (often at least one year), including a detailed needs analysis and
feasibility study. This attention to solid engagement with the host agencies has
helped to build a sense of ownership of the projects among host agency
managers. The one project in which managerial support was a challenge was a
demand-driven project (it was requested by the host agency) and yet not all of
the host managers were on-board, which has affected the project outcomes.
9.3.3 In terms of on-going project management, a manager for one project felt that
each training visit and the overall programme needed to have greater lead time,
to give more time for the process of gaining senior management support and
approval. The SIF Country Manager for this project also noted that coordination

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 was difficult, partly due to understaffing in the host agency and the difficulties of
coordinating the busy schedules of the volunteers and the host agency.

Flexibility to change the focus and scope of projects

9.3.4 Several of the projects were reduced in scope, or changed focus, after the first
few volunteer visits. This was enabled by the SIF flexible approach to project
management, which emphasises responsiveness to local needs and a focus on
successful outcomes. This flexible approach also appreciates that it takes time
for the volunteers to develop relationships and to gain deeper understanding of
the host agency context, needs and appropriate approaches.

Choice of partner organisations

9.3.5 Ten projects in this study focused on one service delivery organisation (a hospital
department), alongside the inclusion of higher education institutions in some
cases (as discussed below). A focus on one hospital department enabled a
contextualised approach to capacity building. Firstly, the volunteers were able to
work with the staff in their own working context and through this, developed
good understanding of their capacities, existing systems and resource limitations.
Secondly, the volunteers were able to provide substantial practical guidance with
patients, which supported skills development. Thirdly, the volunteers were well
placed to identify challenges in organisational systems and work processes, and
to support organisational capacity development (such as promoting new forms of
teamwork and new patient management systems). Overall, this model of
choosing one service delivery organisation enables the volunteers to take a
holistic approach which coherently links individual and organisational capacity
development.
9.3.6 Two of the projects involved trainees from several different NGOs/public
hospitals. These two projects did build the capacity of individual trainees, and
they had broad impact. Yet this project model presents some challenges for both
individual and organisational capacity development. Firstly, for the practical
guidance aspect of the training, the volunteers moved around partner
organisations – this helped them to understand a little about the different
partner contexts, but did not enable a contextualised approach to individual skills
development. Secondly, because there were often just one or two trainees from
each organisation, the trainees of some organisations felt that they did not have
adequate supervision in the use of the skills (this problem was noted by 40% of

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 trainees in the physiotherapy project). Thirdly, while some of the trainees’
organisations have taken up new patient monitoring forms, beyond this there
have been few organisational changes resulting from the two SIF projects which
involved individuals from many different organisations.
9.3.7 The inclusion of a higher education institution or teaching hospital among the
partners of SIF Specialist Team projects helps to promote and enable impacts in
the wider sector, since these institutions provide an existing system and skills for
sharing knowledge. However, the management of such multi-partner projects is
complex and time consuming ‒ for the host agencies, SIF and volunteers. Yet,
when it works, it can help to foster new and strengthened relationships between
the various partners (as in all four projects in this evaluation).

Training of trainers (TOT) approach

9.3.8 The TOT approach to capacity development has been very successful, largely due
to the commitment and motivation of the host agency staff. Nearly all the host
agencies went on to provide cascade training for a large number of people, both
within and outside of the host agencies. One design success factor is the
development of a ‘core team’ of trainers, all of whom went on to train others
(alongside many people who were not selected as trainers).
9.3.9 Yet different approaches to cascade training were used. In some projects, the
volunteers aimed from the outset to develop a new formal course, or to
integrate teaching modules into existing tertiary education curricula. In most of
these projects, the SIF included a higher education institution or teaching
hospital as an organisational partner. The use of existing teaching systems, and
development of new formal courses, has provided a sustainable structure for
cascade training and skill-sharing. Partnering with a teaching organisation also
meant that some host agency staff had existing teaching skills and experience.
Some of the host agencies have also integrated the teaching modules developed
by the SIF volunteers into national training programmes, which has similarly
provided a formal (funded) structure for cascade training – albeit with a limited
duration.
9.3.10 In other projects, the host agencies are not teaching institutions and cascade
training has been pursued in a less structured way. One of these host agencies
has facilitated one fairly substantial training session, but has not developed a
regular structure or system for cascade training. In another two projects (those
which involved individuals from a wide set of different NGOs), most of the

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 trainees provided a short feedback session for their colleagues, but beyond this
there has not been a substantial process of skill-sharing. This suggests the TOT
approach has been less successful when there was no existing teaching structure.
9.3.11 One challenge of cascade training, particularly in host agencies that are not
teaching institutions, is that the staff does not necessarily have the teaching
skills, or confidence in their knowledge, to provide effective training for others.
This raises questions about the quality of cascade training, as noted by several
host agency respondents. Dedicated sessions on ‘how to teach’ within the SIF
volunteer trainings may help in this regard (as provided in two of the SIF
projects). Several respondents also noted that the quality of their cascade
training was also affected by the lack of access to the type of teaching aids used
by the SIF volunteers. Finally, a challenge for cascade training is that it requires
funding. This is particularly the case when training is provided to staff of external
organisations in contexts like Cambodia, where participants expect ‘per diem’
payments, or when host agency staff need to travel to training locations.

Training attachments in Singapore

9.3.12 Training attachments in Singapore are not a fixed or pre-determined component

of the SIF Specialist Team projects; they are agreed to on a case-by-case basis,
depending on their potential to contribute to capacity development. Yet they do
appear to be a fairly regular feature of the projects. The training attachments
take place after host agency staff capacity has been developed to some degree.
According to host agency staff, the training attachments were a significant aspect
of their process of capacity development because they enabled them to really
understand the systems and processes they had been taught by the volunteers.
For example, many trainees explained that the training attachments helped them
to see the efficiency created by triage, organised documentation, nurses being
more independent from doctors, and effective teamwork. Several trainees also
noted that the training attachments changed their personal attitude towards
learning, after being inspired by what they saw as a “strong commitment to
professional development in Singapore”. For many, the training attachment in
Singapore was a turning point in their belief that the systems they had been
taught actually work in practice, and this prompted them to push for change in
their own organisations.
9.3.13 However, a challenge of the training attachments is that the host agency staff
cannot practically engage in the work, due to a lack of authorisation to practice

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 medicine in Singapore. For some trainees, this was a constraint to their deeper
understanding of the medical processes they observed.

Duration and organisation of the volunteer training visits

9.3.14 A small number (5%) of respondents felt that the short duration of each
volunteer training visit was a challenge for skills development. In one project
where each volunteer visit had been one week, one respondent suggested that
longer trainings of two weeks would enable deeper understanding, although
they also noted that it would be difficult for their organisation to release them
from work for two weeks.
9.3.15 Some host agency staff, and most volunteers, noted that there were sometimes
challenges with finding a date for the volunteer visits that worked for all parties
involved. This challenge is partly shaped by the concept of the SIF Specialist Team
model – in which volunteers take leave from work in order to volunteer, and in
many cases do so many times over the duration of the project. The model works
due to the commitment of the volunteers and their Singaporean organisations.
Many of the volunteers’ employers granted them permission to take extended
paid or unpaid leave in order to volunteer.
9.3.16 It is not possible to correlate the overall length of the projects with the ‘level of
success’ of the project, since the projects had very different (and incomparable)
themes and objectives. In general terms, however, longer projects have not
necessarily achieved greater outcomes: the context of the host agency is a more
significant factor in shaping successful outcomes.

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 CHAPTER 10: Social relationships and international understanding built
through a volunteer-driven development approach
This chapter focuses on the social relationships and international understanding built
through the projects. As a people-centred development approach which focuses on changes
in both hard and soft skills and measures changes in attitude and mindset, the evaluation
also explored other unique outcomes volunteers bring to international service, including
social connections and relationships built through the projects. First, we looked at enduring
relationships, i.e. whether volunteers and the communities stayed in touch with each other
and the SIF, the nature of their contact, and the continued impact from keeping in touch.
Second, does people-to-people volunteering contribute to better understanding, i.e. do
perceptions of Singapore and Singaporeans, both at the personal and professional levels,
change. We also examined the extent to which interaction with the volunteers has
influenced the relationships among fellow professionals in the host country, and the
corresponding effect on project outcomes.
10.1 Building people-to-people ties
10.1.1 About half of the host agency managers stayed in touch with the volunteers,
particularly the lead volunteer. Communications are not necessarily frequent,
but are sustained to the level that many host agency managers spoke of a
continuing friendships and social connection. Relationships are largely
maintained through email and occasional phone calls, and meeting-up at
international conferences or when the volunteers visit their country. Where
volunteers and host agency managers have not kept in touch, reasons included
pressures of work (in Vietnam), and limited English language skills (in Cambodia).

10.1.2 In some cases, the relationships are shaped by both friendship and work; while
for others they are just about work, or just about friendship. Among Cambodian
managers, sustained relationships with volunteers are mainly work-related.
Many managers from Cambodia said that it was challenging to discuss work-
related issues over email due to the level of English skills required. They
preferred to discuss technical issues only when SIF volunteers visit or when they
go to Singapore themselves. Among managers from both Indonesia and
Vietnam, relationships are often based on both friendship and work. Work
related contacts are varied: asking work related questions over email, inviting
the volunteers to speak at conferences, or referring patients to Singaporean
specialists. In two cases, the volunteers self-funded a visit to provide additional
training at the host agency after the SIF project closed.

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10.1.3 In most cases, the staff of host agencies explained that only their superiors have
kept in touch with the SIF volunteers. This was also noted in interviews with lead
volunteers who spoke about sustained relationships with mainly the managers
of the host agency. This is because lead volunteers oversee the entire project
and would therefore visit a host agency regularly over several years, from
feasibility study to post-project audit; whereas many other volunteers visited
only a few times.
10.1.4 Some host agency staff said that they maintained ties with the volunteers via
social media such as Facebook, or occasional texts and calls, and that the
volunteers sometimes sent them information on upcoming conferences and
relevant articles. Others explained that, despite a lack of contact, they remain
friends with the volunteers, and that the volunteers would be happy to provide
technical support if asked. Some of the volunteers also explained that they send
gifts to the host agency staff, via friends who are visiting the country, and that
this ‘old-style’ of staying in touch is the most feasible, due to the difficulties of
email and telephone communications. Among Indonesian respondents, the
study trip to Singapore was mentioned by host agency staff as a key factor for
maintaining relationships, since their friendships were strengthened while in
Singapore.
10.1.5 Five of the SIF projects have led to a continued relationship between the
volunteer and the wider host agency, demonstrating strong professional
mentoring and long-term friendships. This has led to continued positive
improvements in the host agency. These relationships are based around both
technical mentoring and friendship. Among the projects are:
Palliative Care project, Vietnam (2005-07): The lead volunteer continued to work
on the development of palliative care in Vietnam after the project closed. This
includes advocacy to change government policy. The volunteer team also helped
the host agency enlarge its professional network by assisting it to join the Asia
Pacific Palliative Care Network (APPCN). The lead volunteer even sought funding
for host agency staff to attend the 2012 APPCN conference.
Otolaryngology project, Vietnam (2003-09): Three years after the completion of
the project, the lead volunteer and host agency staff are still in close contact.
Several of the host agency staff visit Singapore regularly to attend conferences.
When here they would visit some of the Singapore volunteers to catch up and
talk about project developments. The lead volunteer has also visited Vietnam for
conferences and other work, and has continued to discuss improved teaching

110
 systems with the host agency. In this project, strong personal relationships have
also been developed. One example of this is that both the host agency manager
and lead volunteer hosted each other’s children while they were on overseas
work-experience visits.
Physiotherapy project, Cambodia (2005-2010): The host agency and the lead
volunteer continued to work together after the SIF project had closed. The
volunteer has helped enlarge the host agency’s professional network by
facilitating them to join the International Physiotherapy Association, for which
the lead volunteer is a coordinator. The host agency and lead volunteer are now
developing a joint proposal to SIF for a follow-up project to address the next
level of needs.
10.1.6 Yet there are challenges to keeping in touch. Some trainees feel that their level
of English is insufficient to keep in touch on a professional level, but keep in
touch at a personal level. Some also mentioned that email communications are
difficult, due to language difficulties and the lack of email culture among staff of
many host agencies. In many cases, contact was initially sustained but dwindled
over time.
10.1.7 One common comment from nearly all respondents was that they would like the
SIF to support another capacity building project. One of the host agency’s felt
that SIF was needed to mediate such partnerships with Singaporean
organisations, which highlights a challenge - although several other host
agencies have developed direct capacity building relationships with overseas
organisations (such as universities in Australia) since the SIF project closed.

10.2 Perceptions of Singapore and Singaporean

We asked if working alongside with volunteers from the SIF had influenced host
agency understanding about the country and its people. Table 14 summarises the
perceptions formed by host agency staff of Singapore and Singaporeans. Among
the trainees that visited Singapore on the study attachment, their perceptions were
largely positive. Those who had worked with Singaporeans cited discipline, respect,
commitment, flexibility and responsiveness as key characteristics. This suggests
their understanding of the Singapore work ethic and perhaps positive modelling of
some characteristics that contribute to Singapore’s progress. On a personal level,
most host agency staff have come to see the warmer, friendlier and caring side of
Singaporeans, though some perceived overconfidence and a sense of superiority as
negative traits of Singaporeans.

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 10.3 Building of trust and enduring relationships
10.3.1 The building of trust is essential for successful partnerships and relationships. It
helps create a safe environment where people feel comfortable to express ideas
and questions. This increases their willingness to learn and adopt new ideas, and
to follow through on their commitments in a sustained manner.
10.3.2 SIF’s flexible approach to project management has allowed volunteers to take
time to develop relationships, gain an understanding of the host agency’s context
and to develop appropriate approaches. The work of the volunteers have
therefore had an impact on increasing trust at many levels – trainees have
displayed trust in adopting the skills taught to them. These new skills have led to
greater confidence in both doctors and nurses.
10.3.3 The new soft skills learnt by the trainees have led to them being able to build a
higher level of trust with patients, which has in turn increased the acceptance
rate for treatment amongst patients, and led to fewer complaints and increased
patient satisfaction. Trainees in the host communities therefore report higher
levels of confidence, motivation and a desire to continue learning.
Table 14: Perceptions of Singapore and Singaporeans fostered through the SIF project
Perceptions of Singapore

Advanced technology, clean, independent, systematic, compact, modern

Positive
Beautiful, rich

Negative -

Perceptions of Singaporeans: Professional level

Good with time management, punctual, open to questions, flexible and responsive,
committed and teach from the bottom of their hearts.

Singaporeans are rule abiding, disciplined, orderly, hygienic, open, serious,

Positive respectful, civilised, competent, enthusiastic and passionate. They have strong
administrative arrangements and pay attention to details.

They are conscientious, serious about their task, and work well in groups and
teams.

Negative -

Perceptions of Singaporeans: Personal level

Positive Singaporeans are friendly and take care of trainees personally. They are easy to
share with and sociable They are kind and polite, not discriminatory and treat

112
 people equally.

Singaporeans interact more closely with children and patients than us.

Singaporeans are more confident because of their knowledge. They are willing to
transfer their knowledge to others and able to bridge different perceptions.

Negative Some Singaporeans feel superior, more intelligent, overconfident and arrogant, are
(infrequently loud and talkative. Singaporeans are less religious.
mentioned)

10.3.4 Interactions with volunteers have brought about a positive change in internal
dynamics in many host agencies. This is especially so in cases where nurses have
been trained to manage more difficult procedures and their roles redefined to
become more independent with greater responsibility. In such cases, there has
been greater recognition and respect from both patients and doctors. This has
enhanced their status, leading to higher motivation to work and to learn new
skills.
10.3.5 Additionally, the volunteers were able to model the efficiencies of teamwork and
cohesiveness which has led to increased communication between doctors and
nurses and an improved role and status for nurses.
10.3.6 The volunteers have helped host agencies build organisational networks and
professional relationships. Some of the host agencies have displayed an
increased level of coordination between departments. Many have built or
increased external networks due to a number of factors – they have provided
training to other agencies; they have been designated centres of excellence; or
the volunteers have helped them join international professional associations.
10.3.7 These professional relationships have formed the basis of personal relationships
and a higher level of appreciation and understanding of each other’s cultures.

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 CHAPTER 11: Conclusions and recommendation
This evaluation has highlighted a wide variety of capacity development outcomes resulting
from SIF Specialist Team projects. Although there are variations between projects, overall
there have been some impressive impacts at all levels – from individual skills and
professional behaviour, to organisational capacity development and impacts in the wider
sector.

In this concluding chapter, we first outline a set of recommendations for the SIF which arise
from the findings of the evaluation and then provide a broad analysis of the SIF Specialist
Team approach to short-term volunteering.

11.1 Key findings and recommendations

In this section, we outline some key findings and recommendations which arise
from the evaluation.

Project initiation and oversight

11.1.1 Demand-driven projects, and strong engagement with host agency managers,
promote host agency commitment and ownership of projects. In projects where
there was strong commitment and guidance from host agency managers, this
was a critical factor that enabled organisational capacity development.
11.1.2 The SIF’s flexible approach to project management usefully allows for projects to
change focus or scope, which helps to promote responsiveness to local needs
and a focus on successful outcomes. This flexible approach also appreciates that
it takes time for the volunteers to develop relationships and to gain deep
understanding of the host agency context.
11.1.3 Greater lead time before volunteer visits and more advance planning would give
host agencies more time to gain approval from senior managers and to organise
training schedules. This issue relates to the difficulties of coordinating the busy
schedules of the volunteers and host agencies.

The number and type of partner organisations

11.1.4 Projects which focus on one service delivery organisation (e.g. one hospital
department) promote a holistic approach to capacity development and
organisational change. This project model enables volunteers to engage with host
agency staff in their own working contexts. It also helps volunteers understand

114
 the organisational context, and to see where skills, systems and behavioural
issues needed to be worked on together.
11.1.5 Projects which engage a wide set of organisations (with just a few trainees from
each) achieve skills transfer but less organisational changes. This is partly because
few managers from the other participating organisations engage in the training,
which affects their understanding and commitment. Moreover, there is not a
critical mass of newly trained staff in each organisation that can push for change
themselves.
11.1.6 The inclusion of a teaching hospital or a higher education institution provides a
structure for cascade training, which helps to sustain and broaden the skill-
sharing impacts of the projects. Where a formal teaching course is developed as
part of the SIF project, this promotes impacts in the wider profession and sector.

Training approaches used by SIF volunteers

 Interactive teaching methods help to reinforce learning ‒ such as question-
and- answer sessions, group work and role-play.
 Practical guidance with patients supports the learning process, and helps host
agency staff understand how new techniques can be used in practice and
enables clarifications. For the volunteers, practical work with patients also
provides an opportunity to adjust the techniques to the local context and
equipment available within the host agency.
 Patient case presentations are a particularly useful training approach,
especially when host agency staff make the presentations themselves of their
own patients.
 Overall the use of a variety of training approaches reinforces the learning
process.
 The provision of printed training materials, quick reference charts and
manuals helps to deepen and sustain learning.

11.1.7 Behavioural change, such as enhanced professionalism and motivation, is largely

catalysed by working alongside the volunteers and observing their working style.
Yet some direct training approaches can also promote teamwork and
communication, such as team-based practical trainings and guiding the
development of more defined roles for different staff.
11.1.8 The greatest challenge of the skill-sharing process is the language/translations
used in the training sessions. Host agency staff recommended that the SIF
volunteers send training materials to the host agency well in advance of the
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 training sessions to allow for good quality translation, and develop a bilingual
glossary of technical terms.
11.1.9 It is recommended that SIF volunteers ensure that their training is relevant, with
particular regard to the equipment and supplies available within the host agency.
11.1.10 It is recommended that SIF volunteers ensure that their training is pitched at the
right level, and be flexible to making further adjustments as the project
progresses. This includes taking into account the level of education among the
trainees, their prior knowledge of the specialist area, and the educational system
and history in different country contexts. Trainings that are too broad and do not
provide enough depth, can be difficult to apply in practice.
11.1.11 A training attachment in Singapore helps host agency staff understand the
systems and processes they have been taught by the volunteers. It can also
promote professional behavioural change and inspire staff to push for change in
their own organisations.
11.1.12 It is recommended that the SIF volunteers work with the host agency to promote
development of new protocols and guidelines that institutionalise the new
techniques and systems, to promote organisational change and sustainability.

Training of Trainers (TOT)

 The TOT programme should more clearly identify ‘trainers’ (a large

proportion of respondents were not sure if they were trained as a trainer).
 Guidance for trainers should include building their confidence to teach
others, including their understanding that they do not need to be
‘professional trainers’ to share skills with others.
 It is recommended that volunteers should provide training sessions on how to
teach. Since most host agency trainees went on to train others, these
sessions should be provided to all trainees and not limited to staff identified
as ‘trainers’.
 TOT would be improved by the provision of comprehensive training materials
for host agency staff to use when they facilitate cascade training. Ideally, this
would include both lecture slides translated into the local language, and the
teaching aides used by the volunteers (such as mannequins, videos and
medical supplies/equipment).
 The volunteers may be able to support the host agency to source funding for
cascade training, for example through international agencies or national
government training programmes (as in some of the projects in this
evaluation).
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 11.2 The SIF Specialist Team model for short-term volunteering

11.2.1 The analysis in this report has highlighted a wide variety of capacity development
outcomes resulting from SIF Specialist Team projects. Although there are
variations between projects, overall there have been some impressive outcomes
for individual and organisational capacity development as well as significant
impacts in the wider sector and profession.
11.2.2 The SIF Specialist Team projects do encounter similar challenges to other
approaches to short-term volunteering, particularly the difficulties related to
language barriers. However, this model helps to overcome some of the often
mentioned limitations of short-term volunteering.
11.2.3 Strong relationships and understanding: Because the SIF Specialist Team model
enables short-term volunteering within a long-term commitment, it enables the
building of fairly strong relationships and understanding between the volunteers
(particularly the lead volunteer) and host agency staff. This supports the process
of skill-sharing, and promotes appropriate capacity building that responds to local
needs.
11.2.4 High-calibre specialist volunteers: The Specialist Team project model enables
busy professionals to volunteer. Due to this, the SIF is able to attract very high-
calibre specialists. Most of the lead volunteers in the Specialist Team projects are
front-runners in their fields, head of department or coordinators of professional
associations. This strengthens the process of technical skills training.
11.2.5 The volunteers bring their Singaporean organisation into the partnership: Lead
volunteers often draw on their organisations in Singapore to recruit other
volunteer team members. In doing so, the volunteers are able to draw on their
existing team spirit and common understanding of effective techniques and
systems. In some cases, the volunteers’ organisations have donated equipment
and supplies to the host agencies. The volunteers’ organisations in Singapore are
also the setting which host agency staff visit for the training attachments.
11.2.6 Long-term programmes of sustainable capacity building: Because the projects
involve a fairly long-term commitment, the volunteers are able to support a
substantial programme of capacity building and organisational change. The
model can be contrasted with health volunteer projects that provide direct
services such as surgery. Unlike these projects, the SIF model is designed to
develop sustainable capacity in the host agencies.
11.2.7 Cascade training: The TOT component of the projects promotes a sustained
process of skill-sharing. In many cases, it situates the host agency trainers as

117
 catalysts for positive change in their organisations as well as the wider profession
and sector.

11.3 Suggestions for further research

11.3.1 Based on the findings of this evaluation, several interesting areas of investigations
could be pursued in future. Firstly, future evaluations could include a larger set of
SIF volunteers, particularly to deepen the analysis on the effectiveness of training
processes. Such a study would not be entirely focused on impacts but on the
techniques used during the training and the implications on the trainees’ learning.
11.3.2 Secondly, the evaluation could be expanded to other sectors, such as Specialist
Team projects in the education sector. Most of the research tools developed for
this evaluation can be easily adapted for other sectors.
11.3.3 Thirdly, the SIF could review the outcomes of different types of SIF projects, such
as a comparison of the outcomes of SIF Specialist Team projects and In-Field
volunteer projects.
11.3.4 Finally, the SIF’s new Monitoring and Evaluation system includes some standard
indicators for project baselines and outcomes. This data could be used for
periodic comparative analysis of projects.

118
References
Asante, A., Hall, J., and Roberts, G. (2011) A Review of Health Leadership and Management Capacity
in Cambodia. Human Resources for Health Knowledge Hub, University of New South Wales, Sydney
(www.hrhhub.unsw.edu.au)

Brassard, C., Sherraden, M.S. and Lough, B.J. (2010) Emerging Perspectives on International
Volunteerism in Asia. International Forum on Development Service Research Paper, International
Volunteer Co-operation Organisations, pp. 119

DeCamp, M. (2011) ‘Ethical Review of Global Short-term Medical Vounteerism’, HEC Forum, 23: 91-
103

Devereux, Peter (2008). ‘International volunteering for development and sustainability: Outdated
paternalism or a radical response to globalisation’, Development in Practice 18(3), 357-370.

Engel, P., Land, T. and Keijzer, N. (2006) A Balanced Approach to Monitoring and Evaluating Capacity
and Performance: Preliminary Proposal. Maastricht: European Centre for Development Policy
Management (EPCDM)

Febrianna, S-A., Jungbauer, F., Soebono, H., and Coenraads, P-J. (2012) ‘Inventory of the chemicals
and the exposure of the workers’ skin to these at two leather factories in Indonesia’, International
Archive of Occupational and Environmental Health Journal, 85: 517-526

Flynn, M. (2010) ’Impact assessment: Understanding and assessing our contributions to change’,
INTRAC M&E Paper no.7. Oxford: International NGO Training and Research Centre

Green, K., Ly Ngoc Kinh, and Luong Ngoc Khue (2006) Palliative Care in Vietnam: Findings from a
Rapid Situtaion Analysis in Five Provinces. Hanoi: Vietnam Ministry of Health

Green, T., Green, H., Scandlyn, J., and Kestler, A. (2009) ‘Perceptions of short-term medical volunteer
work: A qualitative study in Guatamala’, Globalisation and Health, 5(4): 1-13

Heade, A. (2010) Quality of Trauma Care in Emergency Department of Saiful Anwar General Hospital,
Malang – Indonesia. Forthcoming publication

IRIN (2012) ‘Indonesia healthcare system fails millions’, IRIN Humanitarian News and Analysis, 26
July 2012. UN Office for the Coordination of Humanitarian Affairs

Jakarta Post (2011) Analysis: Indonesia: The Health of the Nation, Jakarta Post 11 May 2011, Jakarta

Land, T. (2000) ’Implementing institutional and capacity development: Conceptual and operational
issues’, Discussion Paper no.14. Maastricht: European Centre for Development Policy Management

Lough, B. (2012) ‘Participatory research on the impact of international volunteerism in Kenya:

Provisional results’ (Unpublished)

119
Lough, B., McBride, A., Sherraden, M., and O’Hara, K. (2011) ‘Capacity-building contributions of
short-term international volunteers’, Journal of Community Practice, 9: 120-137

Lyons, K. (2003) ‘Ambiguities in volunteer tourism: A case study of Australians participating in a J-1
visitor exchange programme’, Tourism Recreation Research, 28(3): 5-13

McGrew, L. (2010) ‘Cultural survival: Partnering with indigenous peoples to defend their lands,
languages and cultures’ , Health Care in Cambodia, 13(3). Cambridge, MA: Cultural Survival

Morgan, P. (2006) The Concept of Capacity. Maastricht: EPCDM

Pasveer, B. (2011) ‘Learning to evaluate capacity development: The making of “facilitating

resourcefulness”‘, Supplement to Issue no. 43, November 2011, Capacity.org

Pitt, E. and Pusponegoro, A. (2005) ‘Pre-hospital care in Indonesia’, Emergency Medicine Journal, 22:
144-147

Pratt, B. (2002) ‘Volunteerism and capacity development’, UNDP Development Policy Journal, 2: 95-
117

Randel, J., German, T., Corderio, M., and Bakre, L., (2005) International Volunteering: Trends, Added
Value and Social Capital. Final report. Oslo, Norway: Development Initiatives

RTCCD, Boston University and Towards Transparency (2011a) Towards a Transparent and Quality
Health Care System: A Qualitative Study on the Causes Perceptions and Impacts of Informal
Payments in Health Services in Vietnam. Berlin: Transparency International

Repair the World (2010) The Worth of What They Do - The impact of short-term immersive Jewish
service-learning on host communities: An exploratory study. Berkeley: Repair the World

Sherraden, M., Lough, B., McBride, A. (2008) ‘Effects of international volunteering and service:
Individual and institutional predictors’, Voluntas 19: 395-421

SIF (2011) SIF’S Approach to Sustainable Capacity Building in Developing Communities in Asia.
Singapore: Singapore International Foundation

Simister, N., with Smith, R,. (2010) ‘Monitoring and evaluating capacity building: Is it really that
difficult?’ INTRAC Praxis Paper no. 23. Oxford: International NGO Training and Research Centre

Suchdev, P., Ahrens, K., Click, E., Macklin, E., Evangelista, D., and Graham, E. (2007) ‘A model for
sustainable short-term international medical trips’, Ambulatory Paediatrics, 7: 317-20

Thanh, N.X., Lofgren, C., Phuc, H.D., Chuc, N.T. and Lindholm, L. (2010) ‘An assessment of the
implementation of the health care funds for the poor policy in rural Vietnam’, Health Policy 98: 58–
64.

UNICEF Website, Country Fact Sheets: http://www.unicef.org/infobycountry/

120
UNICEF (2011), Health Equity in Viet Nam: A Situational Analysis Focused on Maternal and Child
Mortality. Hanoi: UNICEF

USAID (2011) Cambodia Global Health Initiative Strategy, 9 September 2011. USAID:
http://www.ghi.gov/documents/organization/175129.pdf

WHO website, Country Fact Sheets: http://www.who.int/countries/en

White, P., and Cliffe, L. (2000) ‘Matching response to context in complex political emergencies:
“relief”, “development”, “peace-building” or something in-between?’ Disasters, 14(4): 314-342

Wilson, J., Merry, S., and Franz, W. (2012) ‘Rules of engagement: The principles of underserved
global health volunteerism’, The American Journal of Medicine, 125(6): 612-17

World Bank (2010a) Vietnam Development Report (VDR) 2010: Modern Institutions. World Bank:
Hanoi, Vietnam

World Bank (2010b) World Development Indicators 2010. World Bank: Washington DC: World Bank

World Bank (2012) Health Equity and Financial Protection Report – Vietnam. Washington, DC: World
Bank

Zinke, J., (2006) Monitoring and Evaluation of Capacity and Capacity Development. European Centre
for Development Policy Management (ECDPM) Workshop report, Maastricht (Netherlands) 1-3
March 2006. Maastrict: EPCDM

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Annexe 1: Evaluation Timeline
Months (2012) March April May June July August Sept Oct Nov Dec
Phase 1:
Research Design
Selecting projects and establishing
contacts
Interviews: SIF volunteers and
country managers
Literature review
Recruiting local research teams
Designing research tools (survey,
FGD Interviews)
Pre-testing research tools
Phase 2:
Research Implementation
Training of research teams in
country
Local data collection
Data translation
Data clarification
Phase 3:
Data analysis and write up
Data analysis
Write up and editing

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Annexe 2: SIF Concept Note

Concept for 2012 SIF Research Paper

Contribution of SIF’s International Volunteers to Sustainable Change Overseas

Background

In 2010, SIF, together with the International Forum on Development Service (FORUM),
commissioned a research paper titled ‘Innovation & Challenges in International Volunteerism and
Development – an Asian Perspective’. This paper was presented at the IVCO 2010 conference,
hosted in Singapore in October 2011 by SIF.

In 2012, SIF intends to conduct further research to determine the extent to which its short term,
specialist volunteers have contributed and facilitated sustainable change in communities through
carrying out projects in the Asian region. Specialist SIVs (Singapore International Volunteers) work in
teams to carry out skills transfer projects and conduct training to upgrade skills and knowledge of
tertiary institutions in host countries.

The research exercise is scheduled from February to September 2012. The final paper will be
presented at the IVCO Conference in October 2012.

Premise for Research Question

From 1991 to 2011, SIF has sent nearly 2,000 SIVs to 17 countries in both Asia and Africa. SIF fields
both short term and long term SIVs in projects aimed at building the human resource capacity of
overseas communities to achieve socio-economic development and progress. These are generally
referred to as capacity building projects and include both direct service and specialist skills
enhancement projects. For the definitions of these terms, please see Annex 2.

This analytical research paper will study SIF’s capacity building, skills enhancement projects that
have sent short term specialist SIVs in three countries of strategic interest to SIF and where SIF has
been active for at least 5 years: Indonesia, Vietnam and Cambodia. It will examine to what extent
short term specialist SIVs can bring about sustainable change, from the perspective of our overseas
partners. The following points propose the concept of this paper:

What are the outcomes of skills transferred from the specialist SIV to the trainee in the host
agency:

 What kinds of sustainable behavioural change amongst trainees have resulted as a result of
short term specialist skills enhancement projects and assignments?
 What is the change in quality of service provided to the community because of trainees’ new
and/or enhanced skills?
 What is the impact on the professional community or sector resulting from training of
trainers carried out by trainees?
 What are the success factors and challenges associated with the above?

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What relationships and perception of Singapore have been built as a result of the SIF projects:

 What are the perceptions of the relationships which have been built between short specialist
SIVs, SIF and host communities?
 As these projects serve as platforms for building relationships, what are the perceptions of
Singapore and Singaporeans that have been formed as a result of partnership on SIF
projects?
Based on the above three main points, a recommended research title would be ‘Creating sustainable
impact through short term volunteering: An analysis of capacity-building projects in Indonesia,
Vietnam and Cambodia’.

Methodology

This paper will focus on SIF’s specialist skills enhancement projects from two sectors in three
countries. The two sectors identified are healthcare and education. The countries are Indonesia,
Vietnam and Cambodia.

The research will focus on projects which have closed in the above three countries and sectors,
within the period 2002 to 2010. This is for ‘recency’ effect. Looking at projects that have closed too
far back may produce the challenge of attributing causality. In addition, changes in the overseas
partners’ contexts, such as leadership and staff changes in the host agency, may also result in loss of
critical knowledge and data required for the research.

The research approach for this paper will be analytical, and the methodology will be primarily
qualitative. Quantitative data and analyses may be used to support the analyses.

There will be interviews with partners and stakeholders on the ground. The lead researcher,
together with SIF, will determine the number of interviews and focus groups to be conducted. We
suggest that a combination of focus group discussions and interviews with all key administrators,
programme officers and SIVs be conducted with the objective of collating robust data from a good
representation of SIF’s beneficiaries. SIF will assist with the identification of stakeholders. Due to the
inadequate internet connectivity and challenges of using web-based research tools in the host
countries, we propose to use face-to-face in-depth interviews for data collection. This can be
supplemented with focus group discussions with 6-8 people, wherever deemed appropriate. The
cost of this exercise should be cited by the lead researcher in the proposal to SIF.

Additional Considerations Arising from Analysis

Capacity building interventions by long term volunteers are considered generally effective because
of the extended period of engagement with the host communities. Due to the extended time of
engagement and influence, these projects seem more able to create the desired impact by
introducing new ideas and reinforcing them repeatedly over a period of one or two years. We
propose to focus therefore on the impact of short term volunteers in this research but suggest to
include a literature review of studies to be conducted by the research team on the impact of long
term volunteers, so as to provide a comparative analysis of the efficacy of different modes of
volunteering.

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Annexe 3: Survey Questionnaire

SECTION A: Profile of Respondent

1) Gender: Female1 Male2

2) Age group: 20-301 31-402 41-503 More than 504

3) Name of hospital/organisation:_____________________________
4) Job title:_________________________________________
5) Department: __________________________________________
6) What is your professional role: (you may tick more than one if necessary)
1 Doctor

2 Nurse

3 Manager

4 Medical technician

5 Lecturer/educator:

6 Other (please

explain):_________________________________________________________

7) When did you start working with your hospital/organisation: (YEAR)______________

SECTION B: Your work with the SIF volunteers

8) How long did you work with the SIF volunteer in your country? (Number of
months/years______

9) Roughly how many people in your department were trained by SIF volunteers? __________

10) How did the SIF volunteer work with you? Please tick all that are relevant: (note: the small
numbers are for your use in question 11):

1 Provided training classes

2 Visited the wards, surgery or clinic and give advice on work processes

3 Participated in surgery or work with patients

4 Reviewed guidelines or policies and give advice

5 Reviewed my communication with patients and give advice

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 6 Gave advice on leadership, planning or team work

7 Developed training materials (for you to train others) or a manual

8 Provided training on use of equipment

9 Donated of supplies or equipment

10 Provided training attachment in Singapore

11Other (explain):_________________________________________________________

11) Which of the above did you find most useful? (insert number: _____________)

12) Why was this the most useful approach to training?

___________________________________________________________________________

13) You were trained by volunteers from the Singapore International Foundation. After working
with them, what is your impression of Singapore or Singaporeans?
___________________________________________________________________________

SECTION C: Impacts of the capacity building on the trainee’s work

14) What technical medical skills (hard skills) did you gain from the SIF training?
___________________________________________________________________________
15) What was the most useful technical medical skill you gained from the SIF training? Why was
this the most useful? Please give a story from your work to explain your answer
___________________________________________________________________________
16) Did the skills you gained from the SIF training impact on your work with patients? If no, why
not? If yes, please give a story to explain your answer:
___________________________________________________________________________
17) Were there impacts on poorer patients as a result of the SIF training? If yes, please give a
story to explain your answer.
___________________________________________________________________________
18) Were there impacts in the provinces as a result of the SIF training? If yes, please give a story
to explain your answer:
___________________________________________________________________________

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19) Were there changes in your approach to work (soft skills), as a result of the SIF training? If
no, why not? If yes, please give an example:
___________________________________________________________________________
20) Did you see changes see in your colleagues or team after the SIF training? If no, why not. If
yes, please give an example:
___________________________________________________________________________
21) Do you work in a voluntary organisation or private practice in addition to your regular work?
If yes, did you use the skills gained from the SIF training in these other organisations? What
were the impacts?: ___________________________________________________________
22) Were there challenges in using some of the skills. If yes, what were the challenges? You may
tick more than one box. (note: the small numbers are just codes for the analysis):
1 Some of the skills were not relevant to us

2 Some of the training was too advanced

3 We did not have the required finances or equipment

4 There was a lack of commitment to make the changes

5 There was movement of staff or not enough staff

6 There was a lack of guidelines or supervision

7 Other staff were not receptive

8 Change takes time

9 Other factors (explain): __________________________________________________

SECTION D: Changes in your organisation

23) What changes did you see in your department/ organisation after the SIF programme?
___________________________________________________________________________

24) Did you see any lasting impact in your Department/ organisation? YES/ NO, (explain):
___________________________________________________________________________

25) Do you know if the SIF training has led to the building of new structures or purchase of
equipment? If yes, please explain:_______________________________________________

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SECTION E: Training others

26) Were you trained as a trainer?

1 Yes 2 No 3 Not sure

27) Based on the training you received from SIF, did you train others:
1 Yes 2 No

28) Approximately how many people were trained (by you / your team):
____________________

29) Did you / your team train people from:

1 Your department

2 Other Departments of your own hospital/organisation

3 Otherorganisations - if so, how many organisations? (insert number of

organisations):_________________

30) How did you find the experience of training others?

__________________________________________________________________________

31) Were there any challenges in training others?

___________________________________________________________________________

SECTION F: Since the SIF project was completed:

32) Has your department/ organisation received any training since the SIF project: YES/NO

33) If YES, what was the training about? ___________________________________________

34) Do you have any other comment or anything else you would like to add?
__________________________________________________________________________

END OF SURVEY
THANK YOU!

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Annexe 4: Focus Group Discussion Questions
The first 2 questions are about the approaches used in the SIF programme. [20 minutes]

1. Can you explain the different training approaches used in the SIF programme?
[Prompt: for example: classroom training, practical guidance in surgery or wards, preparation of
guidelines, advice on work processes, training in Singapore, etc.)?

2. Which of these approaches to training were more useful? What were the benefits of each of
these approaches to training? What were the challenges?

The next 3 questions are about the technical medical skills (hard skills) you gained from the SIF
training. Technical medical skills include medical knowledge, techniques or use of equipment, etc. [30
minutes]

3. What were some of the more useful technical skills you gained from the SIF training?

4. How have these technical skills improved your performance at work or impacted on patients?
Please give stories to explain the impact

5. What were the challenges of using these new technical skills?

[Prompt. For example: Did it require additional finances or equipment? Was the training
difficult to understand? Did it require reorganisation of teams or work processes? etc]

The next 3 questions are about non-technical skills (soft skills) you gained from the SIF training. Soft
skills include leadership, communication, documentation, team work, planning, work flow,
monitoring, development of guidelines, supervision arrangements, etc. [30 minutes]

6. What were some of the more useful non-technical skills you personally gained from the SIF
programme?

7. How have these non-technical skills improved your performance at work or impacted on the
patients? Please give stories to explain the impact.

8. What were the challenges of using these new technical skills?

Singapore and continued contact with volunteers [10 minutes]

9. The volunteers that came to your organisation were from the Singapore International
Foundation. After working with them, what is your impression of Singapore and Singaporeans?

10. Has any of you kept in touch with the SIF volunteers and if so in what way?”

11. Do you have any other comment or anything else you would like to add? (final question)

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Annexe 5: In-depth Interview Questions (Managers in Host Organisations)
1. Can you briefly explain the original aims of the SIF training programme?

2. The SIF programme included training of trainers. Has any of the staff who were trained as
trainers provided further training for other?
a. If yes, approximately how many people were trained?
b. Who was trained? (people from the department, other departments, other
organisations)
c. If no, what were the challenges of training others?

3. Did you see an impact on the staff’s technical medical skills (hard skills) as a result of the SIF
training? If yes, please give stories of the impacts on their work.

4. Did you see an impact on the staff’s approach to work (soft skills) as a result of the SIF
programme? If not, why not. If yes, please give stories of impacts on their work.
[Prompt: Changes in staff skills? Increased motivation? Better team work? Better
documentation? Better communication with patients?]

5. Did you see an impact on the organisation’s internal processes as a result of the SIF programme?
If not, why not. If yes, please give examples of the impact.
[Prompt: New work processes? New policies or guidelines? Change in team organisation? New
way of monitoring, etc.]

6. Did you see any impact on leadership and planning in your department as a result of the SIF
training? If yes, please give examples.

7. Was any additional budget to your department as a result of the SIF training? If yes, please
explain what the funds were for?

8. Did you see any the impacts on the patients as a result of the SIF programme? If yes, please give
stories of these impacts on particular patients.

9. Did you see any impact on poorer patients as a result of the SIF training? If yes, please give
some stories of the impact on particular patients.

10. Did you see any impacts in the provinces as a result of the SIF training? If yes, please give some
stories of the impact on particular staff and patients.

11. Were there any challenges in making use of the SIF training? Please give examples.

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 [Prompt: Did staff understand the training? Did it require additional finances or equipment?
Were the staff motivated? Were the training topics useful? Some changes are difficult to make]

12. Have there been impacts on other organisations or the wider medical community, as a result of
the SIF programme?
[Prompt: for example: sharing knowledge at conferences, provision of training courses,research,
joint work with other organisations, new networks, influence on national guidelines, etc]

13. Some of the staff may work in voluntary organisations or have private practices in addition to
their regular work. Have the skills been shared in their other work? If yes, what have been the
impacts?

14. Were there any unexpected impacts of the SIF training programme?

15. Have you or your organisation had contact with the SIF volunteers since the training was
completed? If so, what is the nature of your relationship – do they provide technical support or
is the communication for friendship?

16. Is there any evidence on impacts of the SIF training that has been documented (such as patient
feedback, reports or statistics). If so, can we have access to such evidence?
[Note: the Department/ NGO may have provided statistics to the SIF volunteer in the project
Audit. If so, can we have an update of these statistics. We would like to know if the changes
have been sustained].

17. Do you have any other comment or anything else you would like to add? (final question)

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Annexe 6: In-depth Interviews with SIF Volunteers
1. Where did the idea for this SIF project come from? How did the SIF project start? How did you
become involved?

2. What was the situation in the Host Organisation before the project started? What issues did the
project aim to address?

3. What were the different approaches taken in the capacity building programme, and why? Which
of the approaches do you feel worked best, and why?

4. Did you aim to enhance soft skills, such as team work, communication, planning, monitoring and
leadership? If so, how did you approach building capacity on soft skills?

5. What were the most significant impacts of the SIF programme on the trainees?

6. Were there any improvements to leadership, planning, team work or other soft skills?

7. Were there any changes in the overall performance of the organisation?

8. Do you know of any impacts on poorer patients or in the provinces?

9. Were any physical structures or new equipment inspired by the SIF project?

10. Did the Organisation gain additional budget after the SIF project?

11. Overall, did the project achieve its original aims?

12. How was the training of trainers programme approached? Did you choose the trainers? Did you
provide additional coaching to these people? What programme of further training was agreed
by the Host Organisation?

13. Did you help the organisation to cultivate new networks and partnerships with other
organisations?

14. What were the challenges of the project, particularly regarding getting the desired impacts?

15. Are you still in touch with the organisation, and if so in what way (technical advice or
friendship?)

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Annexe 7: Consent Form

Singapore International Foundation

CONSENT FORM

For ALL participants in the evaluation

The Singapore International Foundation (SIF) is evaluating its projects in the health sector. The
evaluation will review the impacts of the projects, now it is some years since they were completed.

The SIF wants to learn from the evaluation. This requires understanding both the successes and
challenges. The information you provide will help improve the SIF programmes in the future.

We would like to know your own perspective.

All responses will remain confidential.

I, undersigned, have read this introduction and acknowledge that I will be interviewed by

Name/ Signature of Facilitator: _______________________________________________

Name/ Signature of Documentation Assistant: _______________________________

Name of respondent: _______________Country:_______________________

Signed (respondent): _________________________________ Date: _________________

Would you like to know the general findings of the evaluation?

If yes, please provide your email address: ______________________________________

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