Medical missions are increasing in frequency and result in billions of dollars’ worth of health care to low- and middle-income countries.
For the most part, these missions are organised by non-governmental organisations such as churches, health-care organisation and charities with a relatively small component being the result of governmental or inter-governmental agencies. In the past there have not been standards or guidelines as to how these missions should be organised and how to measure their effectiveness, both short and long term on the populations that they seek to help. Several decades of research into short-term humanitarian medical missions has led national and international bodies to propose guidelines for organisations which seek to arrange these missions. Those proposing guidelines include the World Health Organization, The European Esther Alliance, the Catholic Health Alliance, and several private actors such as Merck Fellowship for Global Health. These guidelines vary in their comprehensiveness and areas of emphasis, but several important themes appear commonly. We have listed these below.
Assessment of local health-care needs
Often a short-term humanitarian medical mission will start with personnel in a high-income country deciding to offer medical care/services in a low- or middle-income country with virtually no input from the people they seek to help. For example, donors may decide to have a surgical clinic and offer free surgical care; however, from the point of view of the local population the most challenging medical needs may be dental, control of mosquito infestation or the need for a clean water supply, etc. It goes without saying that a short-term humanitarian medical mission should not go beyond the planning stage without local input ideally both from the community and local health-care providers or organisations.
It is important to stress the need for involvement of local health-care providers/organisations. A short-term humanitarian medical mission should be looked at as an alliance between the donor organisation and the local health-care community. The local team can be considered experts in how health care is delivered, what resources are available, the cultural context in which health care takes place, barriers to the delivery of care, and how long-term follow-up can be accomplished after the foreign physicians and nurses have returned home. The relationship between visiting and local health-care teams needs to be based on mutual respect based on what each brings to the table. Visiting health-care providers in particular need to avoid the common “God complex” that they are here to save the native population and know best what should be done on their behalf.
Preparation and plans for implementation
Having assessed the health-care needs and partnered with local health-care providers, the next important issue is planning for the mission. The scope of these plans is extensive but some important issues would include:
1) Is a medical mission needed at all? Can the local health-care need be met by simply donating money or resources to local health-care providers who in many cases will do a better job over the long term in treating their own populations.
2) Is there the availability of appropriate personnel. For example, let us consider a church in a high-income country deciding to run a two-week primary care clinic in Nicaragua. The volunteers are a general surgeon, a dermatologist, an ICU physician and two operating room nurses. This would not be considered appropriate personnel for a primary care clinic in a high-income country, why should this be considered appropriate for a low- or middle-income country? A common theme in many of these guidelines is trying to avoid the mantra that poor care for these populations is better than no care at all. If medical students or residents are going on the mission how are they to be supervised? Are they allowed to assume responsibilities which would not be available to them in their home institutions?
3) Legal/ethical issues: Have the nurses and physicians been licensed to practise medicine in the host country? For some of these missions participants report being told that having a medical licence in their home country is sufficient and they may be unaware that they are practising medicine illegally in the donor country. Have the medications which are brought for the mission been approved by the local equivalent of the Food and Drug Administration? Are the medications labelled in the local language? Have code of conduct and governance issues been discussed with local partners? How are issues of complications and negligence addressed?
Continuity and sustainability
Ideally intervention in the local health care arena should lead to long-term improvement in the health of the population and this inevitably means upgrading of the local health-care system. An overriding question that should be asked is: Is what we are doing sustainable? Is there an opportunity to train local health-care providers to deliver ongoing care in the absence of the visiting physicians? How will the patients fare once the visiting teams have come and gone? An important change in many humanitarian missions has been the recognition that greater and more sustainable impact may be achieved by training and educating local providers as opposed to sending in repeated short term humanitarian missions. A good example is the Charity Resurge which started out doing short-term medical missions for patients with cleft palates and severe burns in Nepal. At first the charity would perform 75-100 surgeries over a two-week period once every year. In the early 2000’s with the encouragement of local physicians they changed the model to that of training local surgeons. Visiting surgeons now spend six months to one year with the primary aim being to teach surgical techniques. With these changes local physicians are now doing more than 1,000 surgeries per year.
Monitoring and evaluation
It may be surprising to know that monitoring and evaluation is not a routine part of the majority of short-term humanitarian missions and that when it does occur evaluation is usually done of the visiting medical team. It is rare for the impact on the community or the local health-care team to be assessed. An anecdotal story that is often told is of a church mission who was building a clinic in a rural area. Every night the locals who were helping would have to correct the defects under the cover of darkness to avoid embarrassing the visiting guests. We can only know what we can measure. A medical mission ideally should not just result in the visiting medical team feeling that they have done charitable work but should also having a positive (hopefully long-term effect) on the community that they have visited. This evaluation can be challenging as the local community may be unwilling to comment negatively on their experience for fear of offending the visiting providers and may ideally be done by independent assessors.
Short-term humanitarian medical missions for the most part have a noble goal of trying to help those who are less fortunate and who lack access to adequate medical care. These efforts are increasing and hopefully will result in meaningful change for health-care systems in low and middle income countries.
Dr Ernest Madu, MD, FACC and Dr Paul Edwards, MD, FACC are consultant cardiologists for the Heart Institute of the Caribbean (HIC) and HIC Heart Hospital. HIC is the regional centre of excellence for cardiovascular care in the English-speaking Caribbean and has pioneered a transformation in the way cardiovascular care is delivered in the region. HIC Heart Hospital is registered by the Ministry of Health and Wellness and is the only heart hospital in Jamaica.