COURSE 9: Quality NGO Management: Written Communication, Partnerships, and Human Resource Management

An organization's greatest strength should be its quality standards, ranging from responsible written communication to responsible management of its human resources.

Responsible Written Communication

Effective internal communication and effective communication with donors and beneficiaries is extremely important for achieving transparency and responsible NGO management. In the case previously mentioned regarding Save the Children, the organization repeatedly sent out thank you notes and cards from specific children receiving aid, though they had died, or had never actually received aid. This lack of transparency and lack of responsible written communication fostered distrust towards the organization since they were not holding themselves accountable for their work. Thus, responsible, timely and accurate written communication is necessary to inform donors about the work of an organization, as well as to ask for funding and to increase revenues. Written communication should include a budget to show the organization’s most recent fiscal year including all expenditures and revenues, as well as up-to-date brochures and press releases. Written communication should also stress the activities the organization has undertaken successfully and what type of outcomes it has achieved. In this way, members of the NGO, as well as potential donors, will be well informed of where their money will be going and how it will be used. (1)

Quality Partnerships and Program Development

Quality partnerships and focused program development are essential. For example, Unite For Sight focuses on delivering and implementing the highest quality programs across all of its program divisions. Unite For Sight's Global Health Delivery division requires that a potential partner pass rigorous analysis to ensure that the highest quality outreach programs are implemented from the start of the partnership. While this ensures the strength of Unite For Sight's programs, it also prevents rapid and unhindered growth. Unite For Sight believes, however, that it is most important to ensure that the organization implements only the highest quality, sustainable programs. Unite For Sight's deliberate growth enables the organization to focus on scaling quality programs, and the organization can therefore be confident that every patient greatly benefits from the care that they receive through the programs.

Quality Human Resources Management

An organization's goal is highly dependent on the willingness and ability of volunteers and staff to implement quality programs. Each participant with an organization is essential to the organization's vision. They bring their own unique sets of interests, academic history, personal experience, and passion, which are all qualities that have the potential to dramatically enhance the impact of the organization's partnerships.

An organization's staff and volunteers have the power to do both incredible good or, conversely, incredible harm. If the principles of sustainable community development are not incorporated judiciously, if the rules of volunteer or staff comportment are not taken seriously, the efficiency and efficacy of the organization's initiatives could be severely jeopardized. If the organization's participants take seriously the best practices of responsible NGO management, however, they have the opportunity to contribute to highly successful programs.

NGOs frequently accept as volunteers anyone who expresses interest in its organization.  The NGO may not have a selection process to ensure that its participants represent the organization well.  However, the saliency of any participant’s actions is certain, so it is important to consider how each participant’s work will be remembered.  Unprofessional behavior will not only be magnified and enduring, but its effects can be far-reaching.  In addition to representing themselves, the participants also represent the organization, all future participants in the organization, and NGOs as a whole.  Any unprofessional conduct would thus reflect poorly and can damage the representation of the NGO.  All participants in an organization must understand that volunteering is a privilege, and that it must be approached with the same level of professionalism as a job.  Similarly, an NGO’s selection process must be similar to a job application.

Unite For Sight's Global Impact Corps division, for example, requires that the volunteer Fellows complete a rigorous application process that is comparable to a university admissions process and, in fact, utilizes the same online admissions software as leading universities. The application includes essay questions and two comprehensive professional or academic evaluations. Accepted Fellows are those who demonstrate intellectual curiosity, an interest in global health, cultural competency, integrity, humility, respect for supervisors, dedication, and other core traits. Upon acceptance, Fellows are required to complete extensive training in global health, cultural competency, social entrepreneurship, and other related topics. Due to these rigorous admissions and training standards, Unite For Sight annually enrolls approximately 300 Fellows, whereas these numbers would be much greater if the organization lowered its standards. However, Unite For Sight strongly believes that it is important for every Global Impact Fellow to meet its standards so that they meaningfully contribute to Unite For Sight's global health delivery programs and also successfully apply their global health knowledge throughout their future studies and careers.

In a health education study in Uganda, an NGO explained that “These people [volunteers] are very useful to us. They are the ones who help in implementation of our activities. In fact this project was developed to be implemented by volunteers. That is why we have recruited and trained about 64 volunteers called peer educators and puppeteers to carry out health education. We believe in using local people because they know best how to reach their fellows. (FP agency staff) … it is good that these young people are working with family planning because we now get information from them about our health problems. You can inquire about family planning from around [from volunteers] without waiting for people to come from town … I think they are useful and we want the organization to train them and make them more qualified to do their work properly. (FGD participant).”  However, the NGO’s volunteers were not properly trained or prepared.  The training process entailed a 1-2 week workshop about the health content, but the volunteers were not trained about how to successfully and effectively implement the health education.  Volunteers reported feeling unprepared.  As the research study concludes, “Volunteers are professionals and, as with paid workers, care is required in their selection and deployment.  In the context of health education, this presupposes deliberate efforts to promote professional standards, skills, and practice.”(2)

It can be challenging to develop a successful human resource management process, but it is essential.  Below we present a vignette involving a volunteer in a challenging situation. Read the summary of her challenge, and then think about how YOU would have responded in the same circumstances.  Then, compare and contrast your response with our re-cap of how the situation should have been dealt with.

The Situation

Madeline is a visiting volunteer at an outreach and sees that more than 200 patients are waiting to be seen. The local nurse asked Madeline to be at the medication and eyeglass dispensing station today with George, who is another visiting volunteer. Madeline sees that a bottleneck to patient flow is accumulating at the patient intake station. Disgruntled about the backup of patients, Madeline thinks to herself, “If the community translators had arrived today on time, we wouldn’t have this problem. People here are so fickle about punctuality.” Madeline is accustomed to the daily routine enough that she feels like she can get started taking patient histories on the dozens of individuals lined up. Madeline also has an ophthalmoscope that she brought from medical school and decides that today will be a good opportunity to practice looking at the retina for each patient for her own learning opportunity. “My hospital adviser back home would be so proud to hear that I am taking what I’ve learned in the States to a developing country!” she thinks. Although she doesn’t have a translator to assist her, this isn’t a deterrent—she has picked up enough words in the local language to hold a basic (albeit somewhat broken) conversation. Besides, as Madeline said, “I have high aims to reach the most amount of people possible, eliminate preventable blindness as soon as possible, and I wanted to contribute my skills to this goal.” One older woman she sees tries to tell her something with very emphatic hand gestures and quick, incomprehensible speech. Since Madeline cannot completely understand, she records the few tid-bits she can interpret, assures the woman she got everything down, and moves on to the next patient. “What does one crazy woman’s babbling matter anyways? The doctors are the experts. They’ll solve her problems when they see her.” The additional patient intake station that Madeline created is not part of the standard station flow that was set up by the ophthalmic nurses at the start, and the patients rotating through Madeline’s intake station are skipping the visual acuity station and walking directly to the ophthalmic examination and diagnosis station. The ophthalmic nurses are silently confused about how today’s setup is causing so much chaos amongst the patients, and they need to take extra time to redirect the patients to the visual acuity station. The patients are also telling the ophthalmic nurses that they were already examined.  By the time the ophthalmic nurses notice that Madeline set up another patient intake station and is looking at patients’ eyes with an ophthalmoscope, she had gotten through 23 patients.

What are Madeline's errors, and how should she have acted in this situation?

The Discussion: Lessons to Remember

While Madeline had good intentions, she committed several lapses in judgment. Let’s discuss a few of them.

1. First of all, Madeline should have remembered that timeliness is not a universal value. “[I]n some traditional societies, punctuality is seen as a Western eccentricity.”(3) It was good that, even though Madeline had noticed this cultural difference during her first couple weeks, it didn’t change her habit of arriving to work on time. While different countries may possess varying perspectives of time, volunteers should assume unless told otherwise that just because patients or supervisors periodically arrive late does not mean volunteers can show up any time they want.

2. Second, Madeline practiced beyond her abilities—and beyond her responsibilities. While she was justified in wanting to utilize her background as a medical student, which undeniably would have been an asset with proper monitoring from supervisors, she stepped outside the boundaries permitted by proper volunteer ethics by using a medical instrument (the ophthalmoscope) without jurisdiction. As Lynn Payer, medical journalist and scientific writer, demonstrates in her book Medicine & Culture, the medical community of the United States is characterized by a “can-do” attitude, one that makes Americans more inclined “to feel it is better to do something rather than not do anything."(4) This makes American medical professionals much more likely to favor more aggressive, intensive procedures, more initiative and risk-taking, than do practitioners from other countries. While independence, drive, and resourcefulness are championed in the States—and can be useful with proper regulation in foreign situations—Madeline’s behavior was in fact denigrated by her superiors. They interpreted her actions as overly bold, abrasive, and disrespectful. Quality NGOs should ensure that all programs are locally led and managed by local healthcare professionals. Madeline subverted the local professionals’ authority by making a unilateral decision on her tasks for the day. She should have inquired about whether it would have been a good idea to set up an additional patient intake session. If her superiors had found this suggestion useful, they could have then directed Madeline to a more strategic spot. Instead, Madeline brazenly disrupted an already efficient system by placing herself in a location that caused patients to skip the visual acuity station.

Likewise, the patients who saw Madeline also expressed dissatisfaction with the way they were treated. Many felt under-valued due to the linguistically complicated and terse encounter. Some of them never returned to the clinic for their surgeries or subsequent consultations. But not only did these patients forgo sight-restoring surgery, they also told fellow villagers how poorly managed the outreach was, discouraging even more people from coming forward to access quality care from the local eye care professionals. Thus, even though Madeline’s decision may seem like a small mistake, it forever changed the attitudes of several locals about eye care. Similarly, the patients who did return despite their discontentment with the way they were treated were still circumspect to buy in to everything the doctors recommended. Hence, Madeline inadvertently created new barriers to care: fear and skepticism. She affected the trust of the patients, who did not understand why they had to be examined twice. She placed additional burden on the ophthalmic nurses, who had to explain to the patients that their first “examination” was not an examination at all, but rather a fledgling student’s impulsive attempt to inspect their retinas without authorization or guidance. The nurses felt disgraced by the patients’ consequent puzzlement.

As seen in Anne Fadiman’s The Spirit Catches You and You Fall Down, lack of trust and non-compliance result when the doctor-patient relationship is compromised. In this poignant anthropological account, Fadiman depicts the tragic case history of Lia Lee, a Hmong immigrant from Laos who, not too long after arriving in California, develops epilepsy. The American doctors try to communicate proper protocol for seizure control to Lia’s parents, who don't speak English, through elaborate gesticulations, color-coded pill charts, and carefully drawn suns and moons on Lia’s orange medication bottles. The Lees, however, are uncooperative and hostile to Western medicine, as it fails to take into account ancient Hmong beliefs about spirituality and bodily phenomena. A pattern of miscommunication, frustration, and cultural altercations take place, ultimately weakening Lia’s already precarious neurological health.(5) This example is given to show that when patients feel slighted in the least, a series of unfortunate events can result.

If Madeline had taken time to contemplate her actions with an attitude of cultural humility, she might have realized that the worth she placed on autonomy was ethnocentric, and not considerate of value differences. To avoid Madeline’s mistake, “[w]e must begin by acknowledging our own social history because recognizing the attitude we bring to our patients enables us to deliver effective care.”(6) It also seems, with her comment about impressing her hospital adviser back home, that Madeline might not be in this trip for the right reasons. In examining the motivations behind tree-huggers’ travel propensities, Maryann Bird exposes the hedonism and naïveté behind “environmentally friendly” expeditions in her Time Magazine article entitled “Ecotourism or Egotourism.”(7) The travelers she describes, all of whom pursue such trips to show how much more respectful and knowledgeable they are about the earth than conventional tourists, end up discrediting themselves by booking airlines, staying at hotels, and consuming imported foods, all of which quickly rack up their carbon emission tally. The article illustrates an important point—volunteers should enter any foreign situation enthusiastic about humbling themselves enough to realize just how little they know. Madeline did just the opposite—she was excited to show just how much she knew and acted accordingly to stroke her own ego.

3. Lastly, we come to the situation with the old woman. There are two primary things wrong with Madeline’s attitude toward this patient.

A) In Dr. Paul Farmer's book Pathologies of Power, there is a section entitled, “Double Standards of Medical ‘Ethics’ for the Developing World." Farmer discusses the deplorable “ironies of inequality” perpetuated by some development agencies and research universities who transport their testing procedures to the Third World.(8) As Farmer states, “The proper beneficiaries of the Universal Declaration of Human Rights—however inexpedient this point might be in our age of individualism and affluence and relativism—are the poor and otherwise disempowered”—those who “are most likely to have their rights violated.”(9) Bringing this point full circle, Madeline should have been prepared to provide the same standard of care to the villagers as she did in the States. There’s no way she would have gotten away with surpassing her hospital adviser’s stamp of approval in the States to examine patients with an instrument she was not authorized to use without supervision. Using the villagers as educational guinea pigs was a presumptuous and disrespectful decision.
B) Dr. Arthur Kleinman—a prominent medical anthropologist and leading figure in global health, social medicine, and cultural psychiatry—makes clear in his book Illness Narratives the importance of carefully recording and interpreting all of the meanings behind a patient’s illness as determined by the patient’s description of his or her interaction with sickness (its perceived etiology, physiological repercussions, and effects on social relationships).(10)

“Illness narratives edify us about how life problems are created, controlled, made meaningful. They also tell us about the way cultural values and social relations shape how we perceive and monitor our bodies, label and categorize bodily symptoms, interpret complaints in the particular context of our life situation; we express our distress through bodily idioms that are both peculiar to distinctive cultural worlds and constrained by our shared human condition.”(11)

Because the ways in which individuals perceive and respond to bodily abnormalities are delicately wrapped up in deeply cultural webs, the practitioner’s role is “the sensitive solicitation of the patient’s and the family’s stories of the illness, the assembling of a mini-ethnography of the changing contexts of chronicity, informed negotiation with alternative lay perspectives on care, and what amounts to a brief medical psychotherapy for the multiple, ongoing threats and losses that make chronic illness profoundly disruptive.”(12)

More pertinently to an NGO’s visiting volunteers (and especially more applicably to Madeline), there needs to be an understanding that although “[t]here may well be enough universality in facial expressions, body movements, and vocalizations of distress for members of other communities to know that we are experiencing some kind of trouble … there are subtleties as well that indicate our past experiences, chief current concerns, and practical ways of coping with the problem. These particularities are so much a part of local assumptions that they are opaque for those to whom our shared life ways are foreign.”(13) In other words, there are certain expressions of or explanations for illness that can only be understood by members of the same cultural background as the patient. Madeline should not have been so quick to dismiss the old woman’s explicit communication of distress. The use of an interpreter, and deeper investigation into and understanding of cultural beliefs, would have helped Madeline record the woman’s concern more accurately and compassionately.

Conclusion

It is essential for an NGO’s volunteers or staff to be equipped with an exceptional understanding of the rules of the road for successful community development, surrender their preconceptions and defer to the authority of local cultural norms. While there is much to be said about the power of humility and sensitivity, this does NOT mean that you have to abandon what makes you you—your experiences, your personality, your passions. While you are called to be an “ethical” volunteer or staff member, we also hope that you are able to learn and grow from your experience by asking questions, applying your unique, invaluable academic and experiential background, and taking time for reflection and introspection. When contemplating what you witness day in and day out, ask yourself the following questions:

• Do discrepancies still exist between my expectations about the community and reality?

• Am I still clinging to preconceived notions about the culture or people?

• What are patient-perceived barriers to care, education, or other resources, and how can I help to eliminate a patient's barriers?

• Am I acting with humility and empathy in all of my interactions?

• Am I respectful when observing and working with the local professionals?

One helpful way to answer these questions is described in Bruce L. Berg’s book Qualitative Research Methods for the Social Sciences. While the following advice is contained within a section about how to write an ethnography—an anthropological examination of a particular community’s values, customs, struggles, and triumphs—it still provisions some kernels of wisdom concerning how an individual should observe and interpret his or her social world. In reading the following quotation, envision yourself as “the researcher,” navigating new, unfamiliar surroundings and trying to make sense of your experiences.

"The “reflexive characteristic implies that the researcher understands that he or she is part of the social world(s) that he or she investigates … Reflexivity further implies a shift in the way we understand data and their collection. To accomplish this, the researcher must make use of an internal dialogue that repeatedly examines what the researcher knows and how the researcher came to know this. To be reflexive is to have an ongoing conversation with yourself. The reflexive ethnographer does not merely report findings as facts but actively constructs interpretations of experiences in the field and then questions how these interpretations actually arose. The ideal result from this process is reflexive knowledge: information that provides insights into the workings of the world and insights on how that knowledge came to be.”(14)

Throughout your management of an NGO, you are going to experience confusing or frustrating emotional responses to certain events. Embrace these moments as opportunities to better understand your worldview. As mentioned previously, volunteers or staff should either have very open worldviews, or they should possess a willingness to have their worldview opened. As Scottish author Robert Louis Stevenson said, “There are no foreign lands. It is the traveler only who is foreign."(15) If you are ever struck by curiosity, perplexity, astonishment, or even repulsion, remember: the local people may be just as perplexed by you. Noting differences of culture with an air of discrimination or intolerance is only an activity of the narrow-minded. Avoiding this takes active practice in cultural reverence, humility, and, ultimately, self-awareness. As long as these traits are cherished and protected, your volunteer participation will be educationally informative, personally enriching, and immeasurably rewarding.

Footnotes

(1) Cravens, J. (2006). “Basic Tips for Fund-raising for Small NGOs in Developing Countries." https://www.ngoconnect.net/sites/default/files/resources/Basic%20Tips%20for%20Fund-raising%20for%20Small%20NGOs%20in%20Developing%20Countries.pdf.

(2) Siu, G. E., & Whyte, S. R. (2009). Increasing access to health education in eastern Uganda: Rethinking the role and preparation of volunteers. Health Education Journal, 68(2), 83-93.

(3) Leggat, P., and Stewart, L. “Culture Shock and Travelers.” Journal of Travel Medicine. 5.2 (1998): 84-88.

(4) Payer, L. Medicine & Culture. (Henry Holt and Company, LLC, 1996): 131.

(5) Fadiman, A. The Spirit Catches You and You Fall Down. (Farrar, Straus and Giroux, 1998).

(6) Roberts, M. “Duffle Bag Medicine.” JAMA. 295.13 (2006): 1491-1492.

(7) Bird, M. (Aug. 18, 2002). “Ecotourism or Egotourism.” Time Magazine.http://www.time.com/time/magazine/article/0,9171,338585,00.html.

(8) Farmer, P. Pathologies of Power: Health, Human Rights, and the New War on the Poor. (University of California Press, 2005): 128.

(9) Ibid, page 212.

(10) “Arthur Kleinman, Professor.” Harvard University: The Department of Anthropology. http://www.fas.harvard.edu/~anthro/social_faculty_pages/social_pages_kleinman.html.

(11) Kleinman, A. Illness Narratives. (Basic Books, 1988).

(12) Ibid, page xiii.

(13) Ibid, page 10.

(14) Ibid, page 10.

(15) Stevenson, R. Quotation. https://www.goodreads.com/quotes/266656-there-are-no-foreign-lands-it-is-the-traveler-only.