One point I have tried to make over the years is that global health programs will build confidence in the local health workers, or they will diminish it. The amount of direction and ownership that the local health system has over the global health project determines the resulting outcome.
Unintentional Disempowerment: A Case Study from Guatemala
One case study we collected from Central America illustrates this point. A general medical team was requested by a missionary in Guatemala. His partner church in Vancouver had several doctors, nurses, and non-medical volunteers who went in response to the request. The missionary directed the team to three communities where they held clinics in local churches. They saw 200 patients per day for seven days. This was in a rural area that they believed had very limited access to healthcare.
However, on the second day, Dr. Hernandez, the primary healthcare provider for the area, arrived to extend his welcome to the team. His clinic was two blocks away. Later, a translator stated that Dr. Hernandez, his cousin, might have to close his clinic, because he was having difficulty making ends meet. Apparently, volunteer medical teams were coming to the area every two to three months. Each time they did, his business dropped off significantly for the weeks to follow. In addition, his office closed during the time the teams were there. He stated, “No one wants to go to a local doctor when they can go to a gringo doctor. Everyone knows the gringo doctors are so much better.”
At church on Sunday, you run into Dr. Hernandez again and learn that he is board certified in Internal Medicine and did a fellowship in public health with the Pan American Health Organization in Washington, D.C.
Adversely Affecting Local Healthcare Providers
As this case study illustrates, global health initiatives can adversely affect local healthcare providers financially and can subvert their place of authority in the community. Such initiatives can also diminish confidence in the local health system and its providers, especially when those providers are community health workers (CHWs) trained by the government or local non-governmental organizations (NGOs). Even hospital-based healthcare delivery programs have been affected by global health initiatives.
An Example from Haiti
When I was in Haiti in the summer of 2010, I met with one of our facility partners. The hospital chief of staff there described serious economic hardship for their hospital after the earthquake. This facility was one of the more functional medical facilities in Haiti, yet it was threatened. Without a payment model for healthcare, it was not sustainable—not in the United States and not in Haiti. This hardship was a result of all the free volunteer care being provided by programs from North America.
He feared that the vast numbers of medical teams could close their hospital since no one wanted to pay for care when they could get it free from staff from North America, which they viewed as being better qualified (J. Fequeire, personal communication, August 1, 2010).
This facility in Haiti operates nine remote rural health clinics in the area, all of which provide basic community services such as immunizations for free. They welcome collaboration with foreign providers but under their supervision and guidance. The hospital has medical records on all of their patients in all of the nine communities and in the hospital. They also welcome specialty surgeons to come and provide services that are not normally available in the region. Their social service representative is adept at discerning which patients have some capacity to pay and which do not. The facility charges fees for surgical services based on the patient’s ability to pay. In this way, the facility is able to use those funds to pay their staff and expenses.
How Would You Feel?
I often ask doctors in the US, “How would you feel if a group of Canadian physicians came and set up a free clinic in a parking lot across the street from your practice and provided free care to all your patients? What if they never even acknowledged you existed except to express to your patients that they should not have to pay for any healthcare services or medication? What if all your patients thought the Canadian physicians were more capable than you and stopped taking the medication you prescribed for the new and better medications from the Canadian physicians?”
Visiting medical and surgical groups can improve the sustainability of local medical facilities and health programs by working under their direction. Working outside their direction often unintentionally hurts them. It can hurt them financially. Also, it can hurt them by diminishing community confidence in their abilities, which can harm the general quality of healthcare available in the region. Programs that engage in global health projects need to be cognizant of these potential effects. This awareness can help us develop strategies that minimize or eliminate these negative outcomes. There is a need and a place for global health initiatives. However, when we design such programs, we need to understand the concepts of payment models and sustainability. Otherwise, our efforts can damage the development process.
Blog Edited by: Lynley Hatcher
Blog Photo by: Ryan Morigeau