How to work in a developing country
Paul Johnstone
Some health professionals seek the exciting challenge of working for a time in a developing country. Uncertainties about taking this step, however, may have to be addressed. It is important to understand your reasons for wanting to work overseas - it is ill advised, for example, to go abroad just to escape job dissatisfaction in Britain. Skills needed for international aid work nowadays centre on low tech community based programmes, and enabling, facilitating, and managing skills are more important than clinical skills. Further training may be necessary. Careful planning both for the work abroad and for a return to work in Britain is advisable; full health insurance cover, for example, is important. Although working in a developing country is largely unrecognised as an asset to a professional career in Britain, attitudes are slowly changing. A spell overseas can be very relevant to a career plan and the NHS.
Working in a developing country can be an exciting experience, personally rewarding, and in some professional specialties, recognised as a positive career step. There is much interest among doctors, nurses, and managers in this country about humanitarian work abroad, but few take up the challenge. There may be many reasons not to go: personal uncertainty; unknown risks to health and safety; indecision about where to go, who to go with, and what to do; mortgage and family commitments; pension and national insurance; job security on return; lack of support from professional colleagues and NHS employers; and the long term risk and benefits to careers. Still, some people want a new and exciting challenge and decide for a spell abroad. This article addresses some of these uncertainties and is a guide to further information for those thinking about working in a developing country.
Why work abroad?
A good starting point is to think about your own reasons for working in a developing country. This suggestion was put to doctors, nurses, and other health professionals attending a workshop run by the International Health Exchange, a London based non-government organisation. Broadly two types of reason were put forward: altruism, including wanting to help and empower others or share skills; and personal reasons, such as gaining experience of different cultures, personal development (through research), personal career development (clinical skills, knowledge), and adventure and a change. The survey was interesting for what a few participants did not immediately say. Only one person thought that working abroad had any relevance to a career in Britain on return. There were also "negative" reasons, including job dissatisfaction and unfulfilled ambitions. It may be important to think carefully before leaving if negative reasons such as these are important: an overseas experience may provide a respite for a while, but the same problems may exist on return, and readjustment to this country could be even more difficult. People work in a developing country because they are committed and want to, not because they cannot cope here. In many circumstances (apart from rapid response relief work), a commitment for at least a year is needed to be useful.
What skills should I have?
The skills needed for international aid work have changed. The traditional view of skills and knowledge as a one way transfer from developed to developing countries is now out of date - particularly for long term development. In addition, the need for the high tech skills of Western medicine and nursing learnt in this country have virtually disappeared: a country with a high rate of infant deaths from diarrhoea and dehydration does not need help to build a high tech special care baby unit.
There are two main areas of international humanitarian assistance for which certain clinical and managerial skills are sought: emergency relief after man made or natural disasters, and long term development aid. In addition, a few but a decreasing number of basic medical posts are needed. Within each area, the opportunities and the types of skills needed are diverse.
Emergency relief work requires common sense and the ability to make decisions quickly sometimes, combined with good clinical and managerial skills. Food, water, drugs, and hospitals are often urgently required, and large intervention programmes need to be planned and implemented quickly. In contrast, long term development has a much lower profile but is equally challenging and needed. Primary health care features prominently, particularly in the training of community volunteers or workers and support to other community based initiatives. Other areas of programme development - such as community development, management of chronic diseases, developing special disease control programmes, and participating in health sector reforms and new approaches to financing - need common sense with good briefing and on some occasions special training. Finally, there is less scope for basic medical jobs now. Several countries already have a surplus of their own medically trained professionals (there were 2000 unemployed doctors in Pakistan in 1989). Opportunities do exist, however - for example, with mission hospitals - and general practice training that included work in casualty departments and obstetrics are important skills for these types of post.
Initially, if you find yourself with skills not entirely applicable to this type of work, further training is available. Many aid agencies and the International Health Exchange offer courses in, for example, teacher training, management support, and epidemiology for beginners. Another option is to consider a diploma (such as in tropical medicine and hygiene at one of the schools or universities with departments of tropical medicine). You should aim to complement your existing skills with new skills in order to facilitate and enable developing communities to help themselves. Perhaps the main skills, often learnt during and not before your first experience of work abroad, are patience and the ability to work in complex, changing, and often difficult circumstances with a high degree of self reliance.
Planning and preparations
Several mechanisms and opportunities already exist to allow some doctors, nurses, and managers to take a career break and work abroad. For example, several health authorities allow sabbaticals and retainer schemes (and occasionally locum cover). Junior doctors may be able to extend study leave or book hospital posts with gaps for overseas work. In this case, it is advisable not to make a clean break or resign from a career post but to arrange work for your return; it is difficult enough to reacclimatise without the pressure of looking for a job. Doctors in training grades could discuss the implications for their specialist training with their postgraduate dean or college's regional adviser.
Once you have decided to work in a developing country and the sort of work you might want to do, the next important question is which organisation you should work for. There are a bewildering number of different agencies and organisations with an array of acronyms and remits. The box outlines the main categories of aid agencies and should be viewed as a beginner's guide when applying for posts.
The most appropriate agency for a new recruit with little overseas experience is probably a voluntary organisation. If you want to continue in international aid work after a substantial overseas experience a much wider range of jobs becomes available, with non-government offices, governments, the United Nations, or the World Health Organisation.
Next comes job applications and interviews. A good source of information on jobs and training is the International Health Exchange, which every two months publishes a magazine with jobs and training advertisements as well as articles on international aid. You could also apply directly to the aid agencies to find out more about their work. You should find out if their terms of service and conditions are going to be suitable for you. Many voluntary organisations offer travel and accommodation as part of the package, and a few even offer to pay school fees and give food allowances. With these included, it is surprisingly easy to survive on a voluntary stipend (and even pay a mortgage). It is important to check that the package includes full health insurance with emergency evacuation cover. A few people have run into extremely severe, life threatening situations, which would have been avoided with emergency "med-evac" cover. Terms and conditions offered by aid agencies vary widely, and it is important to find these out before the interview. Before leaving, it is also advisable to ask about briefing and the support provided from central and regional offices of the organisation (particularly for difficult posts and politically unstable countries). Find out what plans have been arranged if there is an emergency such as a coup d'etat or civil or military unrest.
On return
Most people.do eventually return to Britain, but the culture shock can be traumatic. You'll want to tell everyone about your experiences and no one listens. Euphoria of seeing family and friends quickly gives way to a mild depression (made worse by grey skies). A trip to the supermarket leaves you in shock; bus stop advertisements seem more risque, and you don't understand what your first patients are complaining about.
There are several ways to help overcome the worst culture shocks. The agency should arrange a good debriefing. Opportunities should be made to hand over projects, to update the central office, and to talk through some of the difficult tasks with people who know about the country you worked in. If a debriefing has not been arranged then ask for one, and try to visit others who have worked in the same place. Try to plan your next British job before you return, or even before you leave Britain. You may have to return before the end of your contract for interviews.
Attitudes and benefits to a career in the NHS
Whereas working in a developing country can be personally rewarding, it is largely unrecognised as an asset to a professional career in the NHS (in contrast with some other European countries). Attitudes are slowly changing, however, and as a result the number of links with trusts, practices, and academic departments in developing countries is increasing. There is a growing recognition of international health and aid work in a few royal colleges and faculties - for example, the Royal College of General Practitioners and the Royal College of Nursing.
Another recent development is the shift in Britain's health policy towards an NHS led by primary care. Many models of primary health care have evolved in developing countries over the past three decades, and aid agencies may have contributed to these. Britain's health system could benefit from their experiences, and aid workers are well placed to share knowledge.
The skills acquired through working overseas - managing projects, coping in a crisis, and making difficult decisions in the face of scarce resources (often in harsh and changing conditions) - are all useful in today's NHS. Perhaps now, more than any other time, an international humanitarian aid posting is very relevant to a career plan and the NHS.
International Health Exchange London WC2E 9NA Paul Johnstone registrar in public health
PJ is funded by the Buckingham Health Board.
For further information contact Isobel McConnan, Inter national Health Exchange, 8-10 Dryden Street, London WC2E 9NA. (Accepted 12 June 1995)