Maternal mortality in low- and middle-income countries continues to remain high. The Ugandan Ministry of Health’s Strategic Plan suggests that little, if any, progress has been made in Uganda in terms of improvements in Maternal Health [Millennium Development Goal (MDG) 5] and, more specifically, in reducing maternal mortality. Furthermore, the UNDP report on the MDGs describes Uganda’s progress as ‘stagnant’. The importance of understanding the impact of delays on maternal and neonatal outcomes in low resource settings has been established for some time. Indeed, the ‘3-delays’ model has exposed the need for holistic multi-disciplinary approaches focused on systems change as much as clinical input. The model exposes the contribution of social factors shaping individual agency and care-seeking behaviour. It also identifies complex access issues which, when combined with the lack of timely and adequate care at referral facilities, contributes to extensive and damaging delays. It would be hard to find a piece of research on this topic that does not reference human resource factors or ‘staff shortages’ as a key component of this ‘puzzle’. Having said that, it is rare indeed to see these human resource factors explored in any detail. In the absence of detailed critique (implicit) ‘common sense’ presumptions prevail: namely that the economic conditions at national level lead to inadequacies in the supply of suitably qualified health professionals exacerbated by losses to international emigration. Eight years’ experience of action-research interventions in Uganda combining a range of methods has lead us to a rather stark conclusion: the single most important factor contributing to delays and associated adverse outcomes for mothers and babies in Uganda is the failure of doctors to be present at work during contracted hours. Failure to acknowledge and respond to this sensitive problem will ultimately undermine all other interventions including professional voluntarism which relies on local ‘co-presence’ to be effective. Important steps forward could be achieved within the current resource framework, if the political will existed. International NGOs have exacerbated this problem encouraging forms of internal ‘brain drain’ particularly among doctors. Arguably the system as it is rewards doctors for non-compliance resulting in massive resource inefficiencies.

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Background: Baby wipes have been shown to be safe and effective in maintaining skin integrity when compared to the use of water alone. However, no previous study has compared different formulations of wipe. The aim of the BaSICS study was to identify any differences in incidence of irritant diaper dermatitis (IDD) in infants assigned to three different brands of wipe, all marketed as suitable for neonates, but which contained varying numbers of ingredients. Methods: Women were recruited during the prenatal period. Participants were randomly assigned to receive one of three brands of wipe for use during the first eight weeks following childbirth. All participants received the same nappies. Participants reported their infant's skin integrity on a scale of 1e5 daily using a bespoke smartphone application. Analysis of effect of brand on clinically significant IDD (score 3 or more) incidence was conducted using a negative binomial generalised linear model, controlling for possible confounders at baseline. Analysts were blind to brand of wipe. Results: Of 737 women enrolled, 15 were excluded (admitted to neonatal intensive care, premature or other infant health issues). Of the 722 eligible babies, 698 (97%) remained in the study for the full 8-week duration, 24.6% of whom had IDD at some point during the study. Mothers using the brand with the fewest ingredients reported fewer days of clinically significant nappy rash (score3) than participants using the two other brands (p Z 0.002 and p < 0.001). Severe IDD (grades 4 and 5) was rare (2.4%).

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Chapter 3 examines the effectiveness of traditional capacitybuilding roles focused on the provision of training through Continuing Professional Development (CPD) or Continuing Medical Education. It draws on research evidence to expose the unintended consequences of interventions focused on forms of CPD 'training'. It describes the SVP approach favouring on-the-job co-working and mentoring over formal off-site courses. This approach increases opportunities for genuine learning and confidence in deploying new knowledge. More importantly, this reduces the collateral damage caused by traditional CPD interventions. Notwithstanding these 'successes', our research suggests that the effects of even these interventions can be short-lived. It was at this stage in the project journey that we realised that co-presence, whilst essential, was not sufficient to guarantee knowledge translation and sustained impact.

Chapter 5 applies the knowledge discussed in Chapter 4 to two illustrative case studies. Many interventions tend to represent a simple 'trial and error' approach underpinned by intensive grounded research to facilitate our understanding of change processes or change resistance. Tracking the identification of a 'need' and our experience of designing and monitoring the evaluation of that process, in the light of the new knowledge gained through ongoing research review, improves our understanding of the complexity of social processes. Chapter 5 redefines the objectives of our action-research project from setting out to capture the ingredients of positive change to pro-actively understanding and learning from failure. It attempts, in the context of this potentially debilitating reality, to take stock and identify the characteristics of least-harm interventions to chart the next stage of our journey. It concludes with a series of recommendations aimed at policy makers and volunteer deployment agencies.

Chapter 2 discusses the first part of our journey in operationalising the Sustainable Volunteering Project. It discusses the factors underlying the perceived 'human resource crisis' that is typically blamed for high levels of maternal and newborn mortality in low-resource settings. This is the environment within which professional volunteers find themselves and that they, and their deploying organisations, must negotiate with care. The chapter presents the risks associated with labour substitution or gap-filling roles and explains the importance of the co-presence principle to the SVP.Keywords Human resource crisis Á Labour substitution Á Co-presence INTRODUCTIONChapter 2 outlines the human resource context within which projects such as the SVP are deploying UK clinical volunteers. It begins with a brief presentation of global health 'metrics' emphasising the public view of the human resource crisis in LMICs. These stark metrics play an important (and intentional) role in stimulating the case for AID in all its forms including professional volunteering. Aggregate data on human resources in health form an important component of needs assessment. However, they are profoundly inaccurate in terms of conveying a statistical impression of health worker deployment on the ground due to the very poor and politically loaded nature of record-keeping. Furthermore, they present a profoundly distorted impression of the human resource context within which Health Partnerships and professional volunteers are attempting to promote capacity building. This chapter takes the reader through our own learning from the starting position where we assumed that we were engaging with the simple inability of LMICs to fund the training and deployment of health workers ('they need all the "help" they can get' approach) to our more contextualised understanding of the sheer complexity and power dynamics of human resource (mis)management. The immediate and obvious response to this simplistic 'health worker shortages' model is a labour substitution or service-delivery intervention. This response, whilst appealing to the altruistic and clinical learning needs of volunteers, lacks sustainability. It also undermines public health systems.There is a strong tendency to assume that the solution to health systems crisis in countries like Uganda lies in clinical expertise and that clinicians are best poised to influence global health agenda. We have come to realise that this clinical expertise, whilst highly valuable, needs to be framed and managed within a much more multi-disciplinary and research-informed understanding of human resource systems. And this has important implications for the deployment and management of professional volunteers. The second part of the chapter introduces the concept of 'co-presence'. Co-presence is a well-known concept in the highly skilled migration and knowledge mobilisation literature and our familiarity with this framed our approach to volunteer deployment. Put simply, unless volunteers are working in co-present...