PQMD Healthcare System Strengthening / Medical Mission Initiative Medical Mission Literature Review

July 13, 2016

By Myron Aldrink

Executive Summary

BackgroundOn May 5, 2016, PQMD launched the Healthcare System Strengthening / Medical Mission Initiative (PQMD HSS/MM). The overall goal of the PQMD HSS/MM Initiative is to formalize and improve the practices of Medical Missions to better support Healthcare System Strengthening.

To ensure a thorough understanding of Medical Missions practices and to create a foundation for future developments of the PQMD HSS/MM - a literature review was conducted (June 20 – July 13). The purpose of the literature review was to gain an understanding of current medical mission activities – with special attention paid to standards and best practices and impact metrics. A greater emphasis was given to articles/documents regarding Primary Care, Surgical and Laboratories (the focus areas of the PQMD HSS/MM Initiate).

MethodologyA Systematic Search Process was used (rather than a critical review or meta-analysis). The literature review used two major data bases: 1) PubMed/ MEDLINE 2) Google Scholar. The Literature review included articles written in English published after January 1, 2000. Therefore the literature review could have a US bias.

Quantity and Quality of Articles/DocumentsThe Literature Search produced approximately 340 articles/documents. The vast majority of articles were personal observations and summary of medical mission trip experience. MM documents were generally lacking in terms of quality and data support.

Report FormatThe relevant articles/documents were evaluated and summarized and organized into 5 sections.

1) Profile of Medical Missions

2) Issues/Concerns regarding Medical Missions

3) Standards, Process, Guidance

4) Measurement & Evaluation/Metrics

5) Implications for PQMD HSS/MM

I Profile of Medical Missions

SizeWhile there is no central source or governing body to collects information, the most often quoted size of US medical missions is 6,000 individuals traveling on medical missions annually with a total expenditure of $250 million.

Sending/Receiving countriesThe vast majority of medical missions seem to be from the US, Canada followed by the UK and Australia. Other countries sending a significant number of medical mission teams includes, Germany, South Korea, Cuba, France, Taiwan and China.

The regions receiving the most medical missions were Africa followed by Latin America and Asia. There appears to be a regional skew to medical missions –with the US and Canada sending more MMs to Latin American (especially Honduras) and Europe sending more MMs to Africa and Taiwan/China focusing on Asia.

Type of OrganizationsMedical missions are coordinated and supported by many different organizations, including NGOs, Universities, Corporations, and Governments etc. NGOs account for the largest percentage of medical missions.

The Christian church has a long history related to sending medical missions (thus the “mission” connotation). It is estimated that Faith-based organizations accounts for 30-50% of all medical missions.

Another important sector of medical missions are medical students. Medical student teams are typically called medical brigades (rather than medical mission teams). It is estimated that 40% of medical students participate in medical brigades as a part of their education.

Type of MM programs Medical missions in total provide medical services, training and research. It is estimated that 50 to 60% of international health volunteers carry out clinical work. The others engage in a variety of functions ranging from management or training to policy work.

Capacity building is an important priority of medical mission participants. In one survey, 80% of MM individuals said that improving local health care capacity is important or very important. Thus MM teams are working to have impact beyond immediate patient care and seek to improve local capacity alongside improving individual health.

Primary Care Medical MissionsPrimary Care constitutes the largest number of medical volunteers, followed by surgical medical mission. Primary Care MMs cover a full range of medical needs with the greatest emphasis being maternal health. Unfortunately the quality of articles on Primary Care MMs was marginal. The Primary Care articles either focused on narrow aspects of specific program related to rural community or urban poor areas or the articles were more promotional in tone.

Surgical Medical MissionsIn contrast with primary care, surgery medical mission articles provided detailed information, including analysis on effectiveness, cost and impact. Surgical efforts were categorized into three platforms (short term surgical, trips, self-contained surgical and specialty surgical hospitals) and surgeries types were also analyzed. Overall surgeries deemed most appropriate were Cleft lip/palate, Hernia, and emergency obstetric surgeries. It was also noted that there is a growing emphasis to integrate surgical into primary care efforts

Laboratory Medical MissionsThere were very few articles specific to Laboratory medical Missions. However, there were indication that diagnostic and lab skills and capacity provide essential support to surgical and primary care efforts.

II Issues/Concerns Regarding Medical MissionsThere were many articles regarding issues and concerns related to medical missions. In general there seem to be 5 major concerns:

1) Lack of cultural sensitivity 2) Lack of awareness of local health issues and capabilities 3) Lack of coordination with government and local health systems efforts 4) Questionable cost efficiencies 5) lack of long-term sustainability

So while medical mission provide very valuable services these concerns must be addressed to improve medical mission especially as they relate to supporting local health systems. Quality standards should also address these concerns.

III Standards and Guidance An extensive search was conducted on any information regarding current standard and guidance. There seems to be no universal accepted standards or guidance regarding medical mission practices and procedures. However, a few organizations have develop internal documents on principles, standards, guidelines and best practices. An analysis of the internal documents revealed 8 elements in MMs.

1) Preparation/ Establish Goals

2) Assessment/ Local Needs/ Culturally Appropriate

3) Partnership/Alignment

4) Quality / Code of Conduct/Training Locals

5) Implementation

6) Knowledge transfer

7) Sustainability /Long-term Commitment

8) Monitoring / M&E / Follow-up

IV Measurement & Evaluation / Metrics

Another extensive search was conducted to obtain and information on measurement and evaluation practices of Medical Missions. Again there was no universal accepted standards. However a definative document on medical mission metrics was written by a team from Harvard University lead by Jesse Maki. The Maki team recommended a detailed quantitative research approach starting with a base-need analysis and an evaluation of medical missions based on 6 variables (Cost, Efficiency, Impact, Preparedness, Education and Sustainability)

V Implications for PQMD HSS/MMWhile the literature search does not directly evaluate the PQMD Medical Mission initiative, the information from the literature search seems to support the need for the PQMD HSS/MM initiative. Equally important, no major “red flags” were found regarding the direction of the PQMD Initiative.

1) Lack of Definition/InformationThe lack of quality information on medical missions and the lack of a governing body highlights the opportunity for PQMD to make a significant contribution in this area. The PQMD HSS/MM Initiative and the Community of Practice could become the hub of MM information.

2) Problem IdentificationThe MM problems and issues found in the literature review were consistent with the premise to the PQMD HSS/MM initiative. The PQMD HSS/MM Initiative will be further defining these problems and issues as the base for the development of standards and best practices.

3) No Universal StandardThe literature search did not find any evidence of any universally accepted standards for medical missions. Developing MM standards is the main focus of PQMD HSS/MM. While there were some internal organizational standards, given the collaboration mindset of PQMD HSS/MM and PQMD’s past experience in developing standards, PQMD seems to be in a unique positon to take a leadership role in the development of MM global standards.

4) Desire for Medical Mission Standards (HSS)Likewise no standards seem to exist in the area of MM metrics – the Maki document seems to be very good and well received. In the spirit of collaboration the PQMD HSS/MM initiative would like to connect with the Maki team. Also PQMD is working with the University of Washington on health impact metrics. Therefore the PQMD HSS/MM in conjunction the Maki team and University of Washington could assist in the development of accepted MM metrics.

5) Primary Care/Surgical/ Laboratory FocusThe literature review revealed a trend toward incorporating Surgical and Primary Care – including the WHO statement of Surgery: the neglected component of primary care. The trend supports the decision of PQMD to focus on the three MM health areas (Primary Care, Surgical and Laboratory)

6) Medical Missions support Local Health SystemsThe literature review also revealed that MM thought leaders seem to also focus on sustainability and support for local health systems. Again this support the overall direction of the PQMD Initiative.

So overall the results of the literature review seems to provide support and substantiation for the PQMD Health System Strengthening/Medical Mission initiative.

Note: The detailed findings of this literature review are presented in a “working document” format for discussion with the Oversight Team (rather than a professional Publishable format).

The report should be viewed as qualitative in nature. Information is provided with quotes from the original authors to help provide context. While some data is presented it should be viewed an “example” rather than quantitative information.

Again this literature review is intended to act as a discussion guide for the Oversight team to help make decisions and shape the development of the PQMD Healthcare System Strengthening/Medical Mission Initiative.

BackgroundOn May 5, 2016 PQMD launched the Healthcare System Strengthening / Medical Mission Initiative (PQMD HSS/MM). The overall goal of the PQMD HSS/MM Initiative is to formalize and improve the practices of Medical Missions to better support Healthcare System Strengthening.

The first step of the initiative was to contact PQMD members to obtain information on their medical mission programs and get input regarding the PQMD HSS/MM initiative. A brief 14-question Survey Monkey questionnaire was sent to PQMD members and a 30-minute follow-up interviews were conducted with members that were interested in providing more in-depth information. The PQMD member study was conducted from May 20 to June 15, 2016.

The second step of the PQMD initiative was to conduct a literature review to gain insight from scholarly publication and research on medical missions. This is the report on that literature search.

PurposeThe purpose of the Literature search was to gain a broad understanding of current medical mission practices. Of special attention was paid to articles/documents pertaining to the connection of medical missions to local health system and to standards and best practices that existed in this area. Also, greater emphasis was given to articles on Primary Care, Surgical and Laboratories (the focus areas selected by PQMD for the HSS/MM Initiative) The literature review was conducted from June 20 – July 8, 2016.

MethodologyGiven the broad nature of search, a Systematic Search Process was used (rather than a critical review or meta-analysis). The systematic search process included:

· A broad search of available article/documents

· A appraisal to determine inclusion/exclusion

· A synthesis of information and analysis

· Recommendations for practice

The literature review used two major data bases:1) PubMed/ MEDLINE MEDLINE contained more the 21 million records from over 5,000 medical and health publications. MEDLINE is compiled by the United States National Library of Medicine.

2) Google Scholar. The Google Scholar index contains roughly 160 million articles includes most peer- review online journals academic and books, conference papers, theses and dissertations, preprints, abstracts, technical reports and other scholarly literature.

The Literature review included articles written in English published after January 1, 2000. Therefore there is a possible US bias.

Search TermsThe following terms were used in the literature search:

· Medical Mission/ Foreign Medical Workers/ Medical Brigades/ Medical Volunteer Trips/ Medical Outreach/ Humanitarian Assistance/Volunteerism

· Short-term/Medium-term/Long-term

· Developing Countries/ Low and Middle Income Countries

· Sustainability/ Healthcare Systems/Global Health

· Primary Care/ Community Health/Urban Health

· Surgical or Surgery

· Laboratory or lab

· Standards/ Guidance/Best Practices/Measurement and Evaluation (M&E)/ Impact/ Metrics

Note: The literature search also used combination of terms, for example: Short-term/Medical Missions, Surgical/Medical Brigades, and Sustainable/Community Health

Quantity and Quality of Articles/DocumentsThe Literature Search produced approximately 340 articles/documents as summarized below:

· Medical Missions (137)

· Foreign Medical Workers (46)

· Humanitarian Assistance (29)

· Medical Brigades (11)

· Medical Volunteer trips (8)

· Medical Outreach (7)

· Combination terms and article obtained by reference or citation (217)

Comment: The total of 340 articles/documents was a surprisingly low number given the size and important of medical missions. For example by comparison “Tennis Elbow” produced 909 results in PubMed alone.

While there were some high quality professional documents/articles, the vast majority of articles were personal observations and summary of medical mission trip experience.

The articles themselves often stated these quality concerns. For example:

Tracey P. (2015) –Patti L. Tracey /University of Toronto noted in her PhD dissertation that - most articles were personal, descriptive accounts and testimonies relating to healthcare professionals’ roles and NGO and donor community documenting the various volunteer activities in the mission. Though interesting these reports were not evidence based or evaluative in nature. Some articles clearly represent the glamorization of volunteer missions related service, for example “A Nurse on a Mission”, “Chiropractors Still Work Miracles”, “Save a Child’s Heart: We can and should, “Duffle Bag Missions” and “Volunteering: Beyond an Act of Charity” etc.

Sykes K. (2014) – Dr. Kevin Sykes of the University of Kansa noted that nearly 95% of all publications lack any significant data collection and outcome monitoring from the interventions provided by Short-term Medical Missions. Of the 1164 articles (Sykes) identified only 67 studies were deemed appropriate for quantitative or qualitative analysis. Eight-one of the 67 studies were reports on surgical trips. Furthermore only 50 focused on patient outcomes and only 13 reported late outcomes (after the service were provided)

Literature Review Report FormatThis report contains 5 major sections.

1) Profile of Medical Missions

2) Issues/Concerns regarding Medical Missions

3) Standards, Process, Guidance

4) Metrics

5) Implications for PQMD HSS/MM

In keeping with the systematic search approach -the information was analyzed and synthesized into topic area most meaningful for the PQMD Initiative.

Again, It should also be noted that this report is designed as a “working document” - not a professional report that is publishable. Also due to overall low quantity and quality of articles/documents the report should be considered qualitative in nature. While some data and facts are presented, they should be viewed as “examples” rather than definitive qualitative data. But when possible direct quotation from the author is provided (in italics) to enable the Oversight Committee to get a better context of the subject matter A concerted effort was also made to provide articles/documents from different countries and different types of institutions (Universities, Government, NGO, Hospitals etc.).

I MEDICAL MISSION PROFILESThe first section of the Literature Review provides information on the overall profile of medical missions. This section is organized into four profiles.

1) Medical Missions – Overall

2) Surgical - Medical Missions

3) Primary Care - Medical Missions

4) Laboratory - Medical Missions

1) Medical Missions – Overall ProfileIn general the area of medical missions is not well defined. There is not a central source or governing body that collect information on medical missions. However, the information available was “pieced together” to form a general profile.

Medical Mission - Overview Martiniuk, Manouchehrian, Negin and Zwi (2012) - A team from University of Sydney conducted a literature review of Medical Missions to low and Middle-Income Countries (LMIC) with the following information.

Most missions were short term (1 day to 1 month). The most common sending countries were the US and Canada. The top destination country was Honduras while regionally Africa received the highest number of missions. Health care professionals typically responded to presenting health needs, ranging from primary care to surgical relief. Cleft lips/palates were the most common type of care provided.

The type of medical professionals going on MM is summarized in the graphs below:

A 2013 Survey by AmeriCares supports the Martiniuk data.

The majority of respondents in the AmeriCares survey were licensed health care providers (80%) and the lead medical provider for the outreach team (59%). Their professional affiliation was primarily private practice medicine (36%), followed closely by clinic or hospital (31%). Their sponsoring organization was most often a U.S. registered non-profit or foundation (51%) and another 29 percent identified their sponsoring organization as faith-based.

Medical Students-Medical MissionsThe literature also indicates a large number of medial students participating in medical missions. Often the medical student teams are called medical brigades (rather than medical mission teams). There were many articles/documents specific to medical student emphasizing the value of medical missions to their education and the growing interest by students overall.

Martiniuk also stated that - Medical Schools are also noting increased demand for education elective in Low and Middle-Income Countries. For instance in the United Kingdom a 2002 survey showed that 40% of medical students participated in a 6-8 week mission. The University of California, San Francisco reports 41% of residence in their orthopaedic department alone have been involved in medical missions to LMICs

Sending Countries / Receiving Countries The countries which seem to send the most medical missions are:

· United States

· Canada

· United Kingdom

· Australia

Other countries sending a significant number of medical mission teams includes Germany, South Korea, Cuba, France, Taiwan and China. While actual number of MM individuals is not available, it is believe that the vast majority of MMs are from the US and Canada (possibly 65% of total MMs). It is interesting to note that MMs from the US, Canada, UK and Australia seem to be driven by humanitarian volunteer motivation. Whereas medical missions from Korea, Taiwan, and Cuba seem to also have a nationalist motivation.

The regions receiving the most medical missions are Africa followed by Latin America and Asia. There appears to be a regional skew to medical missions –with the US and Canada sending more MMs to Latin American – with Europe sending more MMs to Africa and Taiwan/China focusing on Asia

Size of Medical MissionsWhile there are no official estimates made regarding the size of medical missions, the most often quoted size of US MM is 6,000 individual with a total expenditure of $250 million annually.

These figure come from - Maki, Qualls, White, Kleefield and Crone (2008). A team of Harvard University medical professionals

The number and popularity of STMMs (Short-Term Medical Missions) have continued to rise and considerable financial and human resources are expended on providing these services. While there is no official or complete compendium of medical mission, a search of the 3 largest mission websites (International Healthcare Opportunities Clearinghouse, Diversions Magazine and Mission Finders) yielded a list of 543 medical mission organizations. Each of these organizations sends anywhere from 3 to 20 missions per year for an annual total of 6,000 short term missions sent to foreign countries from the United States. Some of these STMM are large and well recognized such as Mercy Ships, Project Hope and Operation Smile, but the majority is sponsored by smaller groups and is known only to the people directly involved with the missions. Thus with the 543 organizations sending an average of 10 per mission, at an average expenditure of $50,000 per mission, a very conservative estimate of annual expenditure on STMM is $250 million – but may be considerably more than that. Despite this notable cost expenditure the number and scope of STMMs there is a paucity of literature on the subject.

Work Type of Medical MissionsClinical work is the main function of most medical missions, with training and research also considered important. A survey of European organizations working in Sub-Saharan Africa showed that 50-60% of MM activities was clinical in nature. The finding from Laleman, Kegels, Marchal, Vander Roost, Bogaert, Van Damme (2007) a team from the Institute of Tropical Medicine (Antwerp Belgium) are summarized below:

While virtually nothing has been published on numbers, cost and impact of expatriate staff on health systems and health care delivery. Our survey indicates that 50 to 60% of international health volunteers carry out clinical work, the others are engaged in a variety of functions ranging from management or training to policy work.

Time Duration of Medical MissionsAn AmeriCares survey indicates that most medical missions are “short-term” missions.

AmeriCares (2013) Medical Outreach teams generally take part in what the literature calls “short term medical missions,” (see Chiu et al 2012, Maki et al 2008); 92 percent of trips were less than a month long and the majority (66%) less than two weeks in duration.

Types of Medical Mission OrganizationMany different organizations are involved with Missions including NGOs, Corporations, Universities, and the Military.

Faith-based organizations have a long-history related to volunteerism and medical missions (thus the religious term “mission” is often used). Catholics have been especially engaged in medical missions over the years. It has been noted that faith-NGOs represented 30-50% of medical missions. While no definitive data is available, this estimate seems reasonable given overall faith-based NGO activities cited in articles.

A team - Kagawa, Angelmyer, Montague (2012) – from the University of California San Francisco did a study on the extent of faith-based organization within the overall health systems in developing countries. While the survey did not focus on medical missions, this study provides some perspective of the role of faith-based organizations

Faith-based organizations are considered important partners in health-system strengthening and assuring equity of access to healthcare in developing countries. During the eighteenth and nineteenths centuries mission societies provided medical aid under colonial government in Africa, Asia and Latin America. The Christian Health Association of Africa reports that Christian health networks contribute between 30 – 50 percent of health facilities in their respective countries – see table below

Medical missions for the US and Canada seem to have a high percent of faith-based involvement. The US also seems have corporations which are very active in employee volunteerism, while Europe seems to have more government involvement. University and Medical School participations seem to be high in all regions. Again definitive numbers are not available.

2) Primary Care Medical Mission – Profile

Primary Care - OverviewPrimary Cares has been a major emphasis for the World Health Organization since the 1978 Alma Alta Declaration which defined the following 8 components:

1. Education concerning prevailing health problems and the methods of preventing and controlling them.2. Promotion of food supply and proper nutrition.3. An adequate supply of safe water and basic sanitation.4. Maternal and child health care, including family planning.5. Immunization against major infectious diseases.6. Prevention and control of locally endemic diseases.7. Appropriate treatment of common diseases and injuries.8. Provision of essential medicines.

The World Health Organization also states that the ultimate goal of primary health care is better health for all – with the five key elements being:

1. Reducing exclusion and social disparities in health (universal coverage reforms)2. Organizing health services around people's needs and expectations (service delivery reforms)3. Integrating health into all sectors (public policy reforms)4. Pursuing collaborative models of policy dialogue (leadership reforms)5. Increasing stakeholder participation.

These 5 goals were emphasized in the WHO 2008 World Health Report – Primary Health Care – Now More Than Ever - The summary of Primary Health from the same 2008 report is provide below.

Primary Care Medical Mission - ProfilePrimary Care seems to be the most common type of medical missions followed by surgical medical missions. However there are many more article on surgical medical missions than Primary Care missions. Also many of the Primary Care Articles were emotional and self-promoting providing little program data.

However the AmeriCares survey provides some profile information indicating thatHalf (50%)of the MM teams (50%) identified trip purpose as primary care, while nearly 40 percent said their trip purpose was to conduct surgeries. Of the 10 percent of responses marked “other” trip purpose, 38 percent performed a combination of primary care, surgery and/or dentistry. Primary care teams are most likely to go to an Urban Clinic/Hospitals and surgery teams are most likely to go to Community Health Centers.

Those who indicated that the purpose of their trip was primary care screened larger volumes of people, while surgical trips screened a smaller number. Most surgical teams (87%) performed more than 20 surgeries during their trip –19 percent of surgical teams performed over 100 surgeries.

Primary Care MM – Work Type

A survey by Strand, Mellinger, Slusher, Chen, Pelletier Oct 2013 - Re-imaging Medical Missions: Results of the PRISM Survey – provided information on the type of Primary Care workers.

On average, these missionaries are spending 61.2% of their time on medical work (36.1% on patient care and 25% on other medical areas; see figure 1). This leaves 39.9% of their time spent on a combination of administration, organizational leadership, hosting visitors, and church-related responsibilities

Also the Stand, Mellinger, Slusher, Chen et al (2013) study indicated that Primary Care MM workers thoughts would be most beneficial the type of work that would be - teaching and training and mentoring Christians in medicine as the best to have a positive impact on the health of the people locally. See table below:

The AmeriCares Study (2013) provides evidence that Capacity Building is a major part of medical missions. The Survey conducted with medical mission individuals revealed that:

Improving local health care capacity is ranked as a top priority (30%) or important priority (53%) of teams’ medical outreach mission. Only seven percent of respondents said improving local health care capacity is a low priority and the last 10 percent said it is not possible given the team’s mission. The majority of teams are working to have impact beyond immediate patient care and seek to improve local capacity alongside improving individual health.

Primary Care MM – Healthcare EmphasisPrimary Health (by WHO definition) encompasses a broad spectrum of health needs (8 components). The articles/documents on Primary Health Medical Missions often show that MM teams focus on clinical needs.

Dainton, Chu (2014) University of Toronto – Symptom Cluster on Primary Care Medical Service Trips in Five Regions in Latin America emphasized that - Resources on these trips are generally limited to point-of-care testing, including urinalysis, urine pregnancy testing, and glucometer testing. There is limited availability of advanced laboratory testing and imaging, and this generally requires referral to either a private hospital or to the public hospital, which may be a considerable distance from the community. Considering the popularity and prevalence of these global health experiences, there have been limited descriptions in medical literature of the epidemiology that clinicians can expect to encounter on these trips. However, it is crucial to the preparation of Western clinicians that intend to deploy on a medical service trip to be informed of the symptomatology they are likely to encounter – and provides the following information of patient diagnosis in 5 locations.

.

Primary Health MM – Program Specific

Most Primary Care MM Articles/documents pertain to specific Primary Care programs and very program specific. For examples:

Whitney, Stevens, Bearman (2010) University of Virginia Commonwealth – Medical Relief Service in Rural Honduras: An Assessment of Healthcare Needs and Delivery with a Comparison of Two Neighboring Communities – noted different needs in and the need for specific planning

Rural Honduras has limited access to healthcare. Medical brigades are a common occurrence in extremely underserved areas. The VCU Honduras Outreach Medical Brigada Relief Effort (HOMBRE) administered a Needs Assessment Survey (NAS) in the towns of Coyoles and La Hicaca, two proximal yet geographically distinct areas. Conclusion Residents of La Hicaca are less likely to be obese while Coyoles has an increased prevalence of obesity and gastrointestinal complaints. Dermatological problems, both infectious and non-infectious, were highly prevalent in both communities, but more so in Coyoles. These data are useful for further planning and delivery of healthcare in rural Honduras

Green, Green, Scandlyn, Kestler Starfield (2009) – University of Colorado Denver - Perceptions of short-term medical volunteer work: A qualitative study in Guatemala

Each year medical providers from wealthy countries participate in short-term medical volunteer work in resource-poor countries. Various authors have raised concern that such work has the potential to be harmful to recipient communities. The perceived impact of short-term medical volunteer projects in Guatemala is highly variable and dependent upon the individual project. In this study, project characteristics were identified that are consistently perceived to be either positive or negative. This preliminary study suggests avenues for future study and evaluation of the impact of short-term medical volunteer programs on local health care services

Macinko, Starfield, Erinsho (2009) – Johns Hopkins Institute/New York University Public Health – The Impact of Primary Healthcare on Populations in Low- and Middle- Income Countries –

Results indicate that the bulk of evidence for Primary Health Care (PHC) effectiveness is focused on infant and child health. There is also evidence of the positive role PHC has on population health over time. Although the literature is lacking in rigorous studies … finding generally support the contention that an integrated approach to primary care can improve health.

Primary Care /Surgical - MM Integrations

In recent years there has been an emphasis by the World Health Organization to integrate Primary Health and Surgery. The following information is from the WHO website.

WHO - Surgery: the neglected component of primary care

More than 30 years ago, then Director-General of the WHO Dr. Mahler identified the important role of Surgery in primary health care, citing the availability of emergency surgical treatment in injuries as an essential component. "Without it, in spite of preventive measures…people will not have faith in primary health care…people in need must have access to skilled surgical care at the first-line referral hospitals. Yet the vast majority of the world's population has no access whatsoever to skilled surgical care and little is being done to find a solution." Today, we know that approximately 2 billion people still have no access to basic surgical care. Surgery continues to be the neglected component of primary care, perhaps due to common misconceptions.

Some people think Surgery…

In reality…

addresses only a small part of the global burden of disease

11% of the global burden of disease can be treated with surgery

is not cost-effective

surgical care in Africa is comparable to measles immunization (USD 32.78 vs. 30 per DALY* averted) (Gosselin, et al.)

can only be delivered by surgeons

midwives in Mozambique perform most obstetric operations with good outcomes (Pereira, et al.)

cannot scale

rural, resource-poor surgical programs in Haiti and Mongolia have been successfully scaled-up (Ivers, et al.)

is too complicated to set up and provide (need high-tech equipment)

simple surgical procedures like circumcision to protect against HIV, and casting to correct clubfoot have been done on a large scale

can only be introduced after health systems have been strengthened

building surgical services, infrastructure, and workforce CAN strengthen health systems

* Disability-adjusted life years, equal to one year of healthy life lost

2) Surgical Medical Mission Profile Now thinking about Surgical Medical Missions.

Surgical - OverviewThe WHO list 7 types of surgeries as Emergency and Essential Surgeries.

1. Congenital Anomalies 2. Pregnancy-related complications 3. Injuries violence, disasters4. Infection 5. Cancer 6. Diabetic Complications7. Other surgical conditions

Surgery MM - OverviewThere were a number of good articles/documents on Surgical Medical Missions. However, it should be noted that Surgical Medical Missions are often very specific to the select type of surgery performed. But a general profile of Surgical MM information is summarized below.

Shrime, Sleemi, Ravilla (2014) The Harvard medical teams did study on Charitable Platforms in Global Surgery. They found that surgery is being provides by three platforms - and commented on effectiveness, cost, sustainability and training of each platform.

Approximately 28% of the global burden of disease is surgical (2012 Institute for Health Metrics and Evaluation). In Low and Middle-Income Countries much of this burden is borne by a rapidly growing international charity sector in fragmented platforms

· Short Term Surgical TripsThis platform sends surgeons, anesthesiologists, nurses and/or supporting staff –along with at time surgical instrumentation and technology into LMIC hospitals and clinics for short periods. Organizations such as Operation Smile and numerous orthopedic organizations fit this model

· Self-contained Surgical platformsSignificantly rarer, these NGOs spend longer in-country than the short-term trips (Months to years) but importantly carry their infrastructure with them. Self-contained ships, airplanes, and other modes of transportation these organizations tend not to leave behind any physical structures. Organizations such as Mercy Ships and Cinter Andes fit this model

· Specialty surgical hospitalsAnother common model for surgical delivery by NGOs is specialty hospitals. This platforms establish and entire physical plant either de novo or within an existing structure, dedicated to the treatment of one of a few related surgical conditions. Organizations such as Addis Ababa Fistula Hospital or the Aravind Eye Hospital fit this model.

Prinja, Nandi, Horton, Levin Laxminarayan (2015) - A team from India - School of Public Health did additional research on the surgical charitable Platforms analysis providing cost effectiveness information (pp . Their assessment is summarized below.

Prinja felt that- Basic essential procedure are likely to be cost effective when delivered at any level of the health care system. However, the first-level hospital was found to be the especially cost –effective as a surgical delivery platform with cost of US$10 - $220 per DALY Most surgeries in first-level hospital is emergency surgery. Short term0surgical missions by outside surgeons appear to beneficial only if no other option is available. Otherwise suboptimal outcomes, unfavorable cost-effeteness and lack of sustainability limits their effectiveness. Self-Contained mobile platforms appear to offer good outcomes for people who can reach them but there is no data on their cost-effectiveness and obvious limitations for upscale and national ownership. Specialize hospitals including those providing surgeries for cataracts and obstetric fistula appears to be the most cost effective of the competing options for specialized platform. See chart below (World Book pp 8):

Note: Overall cleft lip/palate surgery is typically considered to be appropriate and cost effective for LMIC. There are documents specific to Operation Smiles with generally positive comments regarding their programs and effectiveness.

There were also studies providing $ cost per surgery (World Bank pp 322) – for example the table below for the World Bank provides cost on maternal reproductive surgeries

Another World Bank study – 2015 International Bank for Reconstruction and development – indicated that surgeries related to Cardiac, Maternal Health and Cleft lip/Palate surgeries would have the greatest impact in relieving the burden of health by specific surgeries. (World Book pp 32)

Finally a survey by a multi university team looked at the US expenditure by NGOs on LMIC surgeries and found that Ophthalmology and Cleft lips/Palettes received the most funding

Gutnik, Dieleman, Dare, Ramos, Rivielle, Meara, Yarmey Shrime (2015). A team from Harvard, Kings College London, Duke and North Carolina- did an analysis on NGO funding support for surgical care.

Funds available for global surgery delivery, capacity building and research are unknown and considered low. The total revenue for2007-2014 for 95 US charity organizations representing 14 specialties totaled $2.67 billion. Ophthalmology and cleft lip/Palates were the top two most funded specialties accounting for more than 7%% of total revenue

Note: While the % of fund for Cleft lips/palates seem possible, the amount for Ophthalmology seems very high (relative to the number of articles on the subject)

Articles on Specific Surgical Medical Missions

There were additional documents/articles regarding surgical-medical missions but these documents pertained to specific surgical programs in a select country, Therefore this information was too small to deduce to an overall profile of general surgical medical missions – examples are listed below:

Merceron, Figueroa, Eichbaum (2015) Vanderbilt University– A model for delivering subspecialty pediatric care in low and middle income country: One organizations early experience (Guatemala)

Bido, Singer, Portela, Ghazinouri et al (2015). Harvard and others– Sustainability Assessment of a Short-Term International Medical Mission (Orthopedics – Dominican Republic)

Corno (2016) University Hospital Leicester UK- Paediatric and congenital cardiac surgery in emergency economies: surgical safari versus educational programs (Cardiac – Multiple countries)

Nwiloh, Edaigbini, Danbauchi, Aminu, Adamu, Oyati (2012) University Teaching hospital Zaria Nigeria - Cardiac surgical experience in northern Nigeria (Cardiac – Nigeria)

Aliu, Corlew, Heisler, Pannucci, Chung (2014) University of Michigan – Building Surgical Capacity in Low Resource Countries: A Qualitative Analysis of Task Shifting from Surgical Volunteers (Plastic Surgery – Multiple countries)

Busse, Azazh, Teklu, Tupesis Woldetsadik, Wubben, Terea (2013) University of Wisconsin – Addis Ababa University - Creating Change through Collaboration: A twinning Partnership to Strengthen Emergency Medicine at Addis Ababa ( Emergency Medicine/Surgery - Ethiopia)

Wright, Walker, Yacoub (2007) Imperial College London UK – Specialist surgery in the developing world: Luxury or Necessity (Cardiac, Plastic, ENT Orthopedic – Kenya and Mozambique)

Hughes, Jandial (2013) Kaiser Portland OR – Ethical consideration in targeted, Neurosurgery missions (Neurosurgery – Multiple countries)

Mitchell, Giiti, Kotecha, Chandika, Pryor, Hartl, Gilyoma (2013) Weill Cornell Medical Center NY – Surgical education at Weill Bugando Medical Centre: Supplementing surgical training and investing in local healthcare providers (various surgeries – Tanzania)

Dempsey Ghazinouri, Diaz, Alcantara, Beagan, Aggouras, Hoagland, Thornhill, Katz (2013) Brigham and Women’s Hospital Boston – Enhancing the quality of international orthopedic medical mission using blue distinction criteria for knee and hip replacement centers ( Orthopedic – Dominican Republic)

Mariano, Ilfeld, Cheng, Nicodemus, Suresh (2008) University of California – San Diego, Northwestern University – Feasibility of ultrasound-guided peripheral nerve block catheters for pain control in pediatric medical missions in developing countries ( Pediatric surgery – Philippines, Ecuador)

Smith, Schecter, Menen, Cripp, Godfrey (2014) Alameda County Health Center Oakland CA- Medical Missions - Overrated or Undervalued- A Single Program Experience (Surgical – Guatemala)

Rominski, Yakubu, Oteng, Peterson, Tagoe, Bell (2015) University of Michigan – The role of short-term volunteers in global health capacity building effort: the Project Hope – GEMC experience (Emergency Medicine – Ghana)

Magee, Raimoundi, Beers, Koech (2012) Operation Smiles– Effectiveness of International Surgical Program Model to Build Local Sustainability (Plastic Surgery – Columbia, Bolivia, Ethiopia)

Bermudez, Trost, Ayala (2013) Operation Smile – Investing in a Surgical Outcome Auditing System (Plastic Surgery – Multiple countries)

Luboga, Macfarlane, von Schreeb, Kruk, Cherian et al (2009) Makerere University-Uganda, University of California San Fransisco, Karolinka Institute – Sweden, University of Michigan – Increasing Access to Surgical Services in Sub-Saharan Africa: Priorities for National and International Agencies Recommended by the Bellagio Essential Surgery Group (General Surgery – Uganda)

4) Laboratory Medical Mission Profile

WHO classifies Laboratory facilities in 4 levels 1. Biosafety Level 1, basic2. Biosafety Level 2, containment 3.Biosafety Level 3, maximum containment4. Biosafety Level 4. Biosafety level

These designations are based on a composite of the design features, construction, containment facilities, equipment, practices and operational procedures required for working with agents from the various risk groups.

There were very few articles/documents specifically about Laboratory Medical Missions, however, the important of laboratory diagnostics was mentioned in relationship to providing support for Primary Care and Surgical efforts. For example in Pearson, Steven. Sanogo, Bearman (2012) Virginia Commonwealth article – Access to Healthcare vary among Three Neighboring Communities in Northern Honduras states

Major limitations in access included “never” being able to obtain a blood test, obtain radiology

services, and see a specialist. Major barriers were cost, distance, facility overcrowding

Wilson, Gradus, Zimmerman (2010) University of Colorado – in the article The Role of Local Public Health Laboratories Argues stated the need for more local public health laboratories

First, many local laboratories provide testing at the site of patient care (e.g., sexually transmitted infection clinics) or address local environmental issues (e.g., water quality). Second, local PHLs support the missions of local public health departments Third, local PHLs often serve as conduits, collecting specimens for various state-level screening and disease-control programs; and while they may not perform the testing, local PHLs are responsible for tracking specimens, ordering tests, and reporting results. Fourth, local PHLs often serve as surge capacity for state PHLs, particularly for testing to support emergency response. Last, local PHLs work with and are typically co-located in the local public health agency with other public health programs. Local PHL professionals work as a team with investigators, inspectors, and community and public health medical professionals and, thus, are poised to provide rapid and relevant responses to community needs.

However one organization - Pathologist Overseas – seems to be the leader regarding laboratory medical missions. The following article summarized their activities.

Pathologists Overseas is a nonprofit organization that has been coordinating the efforts of volunteer pathologists and technologists for 19 years to improve and provide affordable pathology services to underserved patients worldwide. This is accomplished by aiding and establishing pathology laboratories, providing diagnostic pathology services, and training local physicians as pathologists. Projects have been completed or are currently active in Kenya, Eritrea, Madagascar, Ghana, Nepal, Bhutan, Peru, El Salvador, and St Lucia. The main challenge is finding enough volunteers to provide uninterrupted service to maintain a project. Our goal is to build on these experiences and continue to both support existing and establish more pathology laboratories worldwide.

II ISSUES REGARDING MEDICAL MISSIONS

The next section looks at the issues regarding medical missions. There were many articles written which had very strong opinion regarding Medical Missions

· positive toward medical missions

· negative towards medical missions

But instead of citing all these articles, three articles were selected with summarize the issues and concerns regarding Medical Missions. These articles seems to have a balanced approach towards medical missions – including some suggestions and commentary

1) Martiniuk, Negin (2012) University of Sydney Medical School - Voluntourism: the downside of medical Missions.

Our recent study of 230 published accounts of short-term medical mission to poor countries over the last 25 years reveals there are serious concerns about their sustainability, financial transparency, ethical standards and appropriateness in meeting the real needs of your neighbours. We found that the USA, Canada and Australia dispatched the most missions.

The health professionals who went on these mission gained a great deal personally and saw volunteer experience as opportunities to reconnect to why they chose to become health workers. And the services provided helped a number of people in nee who might not have had access to care otherwise. While these mission are fundamentally altruistic and led by people who “want to make a difference” there are a number of negative aspects.

· A number of rich-world doctors demonstrate a lack of awareness about the realities of health care in developing countries.

· Visiting health workers often make little effort to understand health needs and culture

· Furthermore, insufficient attention is given to critical issues of follow-up and ongoing care – often not knowing the local system well enough, there is a failure to refer patients for ongoing care

· Short term medical mission are also not the best use of limited financial and human resources. The cost involved in financing missions such as airfare, accommodations, visa costs, custom fees for medicine and medical equipment are considerable

· There were also suggestions that some medical participants were not as altruistic as claimed. Mission by Canadian health worker to the Caribbean increase during the cold Canadian winter. Some medical students see time working in developing countries as a “rite of passage” for admission into residency. One report saw patients in developing countries as a “population to perfect their surgical skills”

Healthcare work overseas needs to take into account strengthening the health systems of communities as a whole and for the long-run and not providing immediate Band-Aid solutions for a handful of individual patients. Considering their popularity, there is a need to harness the positive power of these medical mission by increasing the partnership with people in developing countries and mentoring over the long term. This will help people increase their skills to ultimately reduce the need for medical missions. As with most aid the ultimate goal has to be to make oneself redundant. More capacity building more focus on prevention and more cost-effective use of funds for infrastructure are needed to achieve that goal.

2) Wilson, Merry, Franz (2012) – Mayo Clinic Rules of Engagement: The Principles of Underserved Global Health Volunteerism, Another article from a team from the Mayo Clinic also and provides commentary and suggestion for the development of set of guiding principles – by focusing on preventing harm

● Interest and participation in global health projects by students and health providers are increasing throughout the United States.

● Significant harm to communities may occur through the lack of public health focus, appropriate skills, medical supervision, familiarity with local diseases and customs, and the subsequent creation of community dependency.

● To reduce the risk of harm, we suggest a set of guiding principles: quality service, sustainability, professionalism, and safety.

3) Dr. Judith Lasker - Future book research - Short-Term International Volunteer Programs in HealthThe third article on medical mission issues - is not a summary of an article/document but instead is a request from an author for her upcoming book on medical mission. Dr. Lakser is asking the public to provide comment and input to help with her book. However, the questions Dr. Lasker asked are similar to the issues raised in the other two articles

Judith N. Lasker Professor of Sociology at Lehigh University, has been immersed in research on international health volunteerism. Below she has offered a summary of her forthcoming book. This pre-publication dialogue further indicated the key Medical Mission issues.

Short-term volunteer service trips across national borders are increasingly popular in Europe and in the United States.  Whether for a few days or a few months, hundreds of thousands of people travel annually from wealthier to poorer countries to participate in programs intended to improve the health and well-being of citizens in underserved communities.  Despite their growing popularity, there has been little attention to the question of whether these volunteer efforts actually contribute to improvements for the recipient communities, and whether there might be costs to those communities that diminish or even outweigh the supposed/theoretical benefits from the service efforts.

Most people assume that poor people are benefiting from the goodwill and skills of the volunteers. Yet, with such an enormous human and economic investment in health service trips, it is essential to gain a better understanding of this ‘industry’ and to examine if, and how, the recipients of service projects are benefitting. Are service trips, in their existing frameworks, the best allocation of precious resources to improve the lives of people in poor communities of the world?  Are there ways to improve short-term volunteer programs in order to increase their value?

To date, most attention to this phenomenon has focused on the advantages to the volunteers and their sponsoring organizations (Caprara et al., 2007; DeGilder et al., 2005; Sherraden et al., 2008; Turker, 2009).  The goal of my book is to focus on the benefits, and possible costs, of short-term health-related service trips for host communities.  Do these programs really make a positive difference in the health of people in poor countries by contributing to better services, a healthier environment, or healthier behaviors? Is it possible in a few weeks or months (the timespan of most trips) to have a measurable effect, or is it perhaps the cumulative effect of many such visits that makes a difference? What are the characteristics of programs that appear to be most beneficial for the health of host communities? What is being done to evaluate the impact of short-term volunteer trips, to see if they actually ‘help’?  So far, very little.

III Standards, Guidance, Best Practices/Principles

The next section of the Lit review pertains to information of MM Standards, Guidelines, Best Practices and Principles

The Literature search identified 9 organizations which had Standards, Guidelines, Best Practices or Principles regarding medical mission. These organization are:

· AmeriCares - Medical Outreach Best Practices (2013)

· Catholic Health Association - Recommendations for Practice (2015)

· Pfizer /Brooking Institute - Best Practices for International Corporate Volunteering (2007)

· Standards of Excellence – Short Term Medical Missions (2016 - Web link)

· International guidelines for the successful organization of humanitarian medical missions (HMMs) during peacetime Singapore Healthcare (2015)

· Association of Medicine – The Principles of Underserved Global Health Volunteerism (2013)

· PAHO – Values, Principles and Elements of Primary Health Care (2007)

· WHO/World Economic Forum – Guiding Principles for Public-Private Collaboration for Humanitarian Action (2008)

· University of Wisconsin - Model for International Medical Education Partnerships (2013)

When Comparing and analyzing the Standards/Guidelines/Best Practices there seems to be some basic similarities. In general there seems to be 8 components regarding MM Best Practices – as summarized in a color coded table below

 

Preparation/ Establish Goals

 

Assessment/ Local Needs/ Culturally Appropriate

 

Partnership/Alignment

 

Quality / Code of Conduct/Training Locals

 

Implementation

 

Knowledge transfer

 

Sustainability /Long-term Commitment

 

Monitoring / M&E / Follow-up

These color codes are used to categorize the Standards, Guidelines, Best Practices or Principles of the 9 organizations on the next page.

Please see the full detail of the Standards, Guidelines, Best Practices or Principles of each of the 9 organizations on the next pages.

Guiding Principles

Recommendation for Practice

Recommendations

1. Set goals before roles: Identify the business motivations for volunteering and develop programs to fit goals

2. Walk before you run: Determine which of the two operational models to pursue—cross border service or local service—based on the company’s level of experience with international programs and its desired presence in a target country

3. Lead with leverage: Opportunities to create social impact will be greater if companies leverage employees’ workplace skills and knowledge

4. Align with philanthropic and CSR activities: Look for opportunities to combine volunteering programs with ongoing philanthropic or CSR work

5. Partner proactively: Partnerships can provide access to resources the company may not have

6. Invest in infrastructure: Ensure adequate internal resources to manage volunteering programs

7. Communicate clearly: Be up-front about the motivations and benefits of the program, and communicate those messages to internal and external stakeholders

1. God-Centeredness An excellent short-term mission seeks first God’s glory and his kingdom, and is expressed through our:

· Purpose — Centering on God’s glory and his ends throughout our entire STM process

· Lives — Sound biblical doctrine, persistent prayer, and godliness in our thoughts, words, and deeds

· Methods — Wise, biblical, and culturally-appropriate methods which bear spiritual fruit

2.  Empowering Partnerships An excellent short-term mission establishes healthy, interdependent, on-going relationships between sending and receiving partners, and is expressed by:

· Primary focus on intended receptors

· Plans which benefit all participants

· Mutual trust and accountability

3.  Mutual Design An excellent short-term mission collaboratively plans each specific outreach for the benefit of all participants, and is expressed by:

· On-field methods and activities aligned to long-term strategies of the partnership

· Goer-guests’ ability to implement their part of the plan

· Host receivers’ ability to implement their part of the plan

4.  Comprehensive Administration An excellent short-term mission exhibits integrity through reliable set-up and thorough administration for all participants, and is expressed by:

· Truthfulness in promotion, finances, and reporting results

· Appropriate risk management

· Quality program delivery and support logistics

5.  Qualified Leadership An excellent short-term mission screens, trains, and develops capable leadership for all participants, and is expressed by:

· Character — Spiritually mature servant leadership

· Skills — Prepared, competent, organized, and accountable leadership

· Values — Empowering and equipping leadership

6.  Appropriate Training An excellent short-term mission prepares and equips all participants for the mutually designed outreach, and is expressed by:

1) Biblical, appropriate, and timely training

2) On-going training and equipping (pre-field, on-field, post-field)

3) Qualified trainers

7.  Thorough Follow Through An excellent short-term mission assures evaluation, debriefing and appropriate follow-through for all participants, and is expressed by:

· Comprehensive debriefing of all participants (pre-field, on-field, post-field)

· Thoughtful and appropriate follow-through for goer-guests

· On-field and post-field evaluation among sending and receiving partners

(PAHO/WHO 2007) Primary Health Care

In PAHO has called for a renewal and a re-articulation of the values, principles, and elements of a PHC program in the Americas.

Below are the characteristics of PHC most relevant to our present discussion.

Primary health care:

• is oriented towards quality;

• is sustainable; • involves individual and community participation;

• is integrated with other activities of human development;

• is culturally acceptable; • includes referrals to more specialized care as necessary;

• includes services of health promotion and prevention, early diagnoses, and self-care;

• provides curative, rehabilitative, and palliative care;

• is focused on populations;

• provides appropriate and effective care. (PAHO/WHO 2007, 23-48) Throughout the description of these characteristics, PAHO

1) Leveraging of Core Competencies Partnerships between humanitarian actors and private sector companies should be developed in which the core competencies of both parties are valued and leveraged.

2) Needs-Driven Both parties should work together to ensure that all of their collaborative efforts are aimed at meeting identified needs and respect the culture, customs, and structures of affected communities.

3) Standards and Codes of Conduct The humanitarian community has developed professional standards and codes of conduct for the provision of quality assistance.

4) Relationships with Governments Both parties will work together to engage national and local authorities as much as possible in their collaborative efforts if appropriate

5) Building Local Capacity Both parties will aim to build local skills and resources in the context of their collaborative efforts.

6) Donation Cost Coverage The acceptance of in-kind donations sometimes necessitates significant additional costs on the part of humanitarian assistance providers.

7) Distinction between humanitarian and commercial activities Both parties should establish a clear separation between their divisions managing public-private partnerships for humanitarian action and those responsible for procurement.

8) Public Relations Both parties will work together to ensure that their public relations activities accurately reflect their collaborative efforts and respect affected communities

9) Reporting, Monitoring and Evaluation Both parties will work together to ensure that they report publicly on their collaborative efforts using clear, consistent, and transparent reporting policies.

10) Predictability Both parties should work together to develop partnerships that are predictable in nature.

University of Wisconsin Madison

IV Measurement & Evaluations / Metrics

The literature search also revealed a lack of metrics regarding medical missions. Several articles focused specifically on the need for metrics to determine the effectiveness of MM programs including:

Kelly, Doyle, Weakliam, Schoenmann (2015) – CBI Liverpool UK - A rapid evidence review of Institution Health Partnerships. This UK team conducted a review of IHP and other humanitarian programs. Their conclusion was:

Evidence for the effectiveness IHP is thin both in terms of quantity and academic rigour. There is a need to better define and differentiate in order to measure and compare effectiveness across such a diverse group. Effectiveness needs to be measured at the level of individual partnerships, the bodies that facilitate partnership programmes and the level of health service delivery. There is a need to develop indicators and frameworks that specifically address the benefits and values of partnership working and how these relate to effectiveness.

Snyder, Dharamsi, Crooks (2011) – Simon Frazer Univerity Bristih Columbia Canada – Fly-by Medical

Care: Conceptualizing the global and social responsibilities of medical tourist and physician voluntourist – further states the need for better measurement on an ethical basis

However the most extensive study regarding medical mission metrics was done by a team from Harvard lead by Jesse Maki.

Maki, Qualls, White, Kleefield, Crone (2008) - Harvard University team – Health Impact assessment and short term medical Missions: A method study to evaluate quality of care. Maki states the need for metrics but also provides a standardized tool for evaluation of Short-term Medical Mission.

Short-term medical missions (STMMs) are a well-established means of providing health care to the developing world. Despite over 250 million dollars and thousands of volunteer hours dedicated to STMMs, there is a lack of standardized evaluation to assess patient safety, quality control, and mission impact.

An evaluation tool was created assessing 6 major and 30 minor factors identified as important to the quality of STMMs This provides a standardized tool for STMM evaluation. Use of the assessment instrument identified areas of strength and weakness of a particular mission, and delineated general trends in performance compared to other STMMs. We anticipate that the use of this tool may improve the quality of care provided by missions, and stimulate solution-sharing and scholarly discussion among missions.

In summary the Maki evaluation process is a 3 phase approach

Phase I – Base-need AnalysisPhase II- Survey design

Cost - A measure of the awareness of the total financial expenditure of the mission, and accuracy of assessing cost, including per patient cost, and the factors that influence it.

Efficiency - A measure of productivity; comparing measurable outcomes, such as the number of patients treated and complication rates, to time and resources spent.

Impact - A measure of the quality and effectiveness of the collective medical interventions as perceived by patients and providers.

Preparedness - A measure of the ability to function as an effective team, with other medical missions, and within the overall context of the medical system of the host country.

Education - A measure of the resources directed to providing responsible and accurate education, mentorship, and training to recipients and local health care workers.

Sustainability - A measure of the long-term focus of the mission, including fostering independence through building local capacity.

Maki concludes by stating - Without proper evaluation standards, issues on patient safety, quality control, and impact assessment are easily overlooked since STMMs are often locally organized and privately funded without restrictions. This can lead to disaster.

V Implications for PQMD HSS/MMWhile the literature search can not directly evaluate the PQMD Medical Mission initiative, the information from the literature search seems to support the PQMD HSS/MM initiative. Equally important, no major “red flags” were found regarding the direction of the PQMD Initiative.

1) Lack of Definition/InformationThe lack of quality information on medical missions and the lack of a governing body highlights the opportunity for PQMD to make a significant contribution in this area. The PQMD HSS/MM Initiative and the Community of Practice could become the hub of MM information.

2) Problem IdentificationThe MM problems and issues found in the literature review were consistent with the premise to the PQMD HSS/MM initiative. The PQMD HSS/MM Initiative will be further defining these problems and issues as the base for the development of standards and best practices.

3) No Universal StandardThe literature search did not find any evidence of any universally accepted standards for medical missions. Developing MM standards is the main focus of PQMD HSS/MM. While there were some internal organizational standards, given the collaboration mindset of PQMD HSS/MM and PQMD’s past experience in developing standards, PQMD seems to be in a unique positon to take a leadership role in the development of MM global standards.

4) Desire for Medical Mission Standards (HSS)Likewise no standards seem to exist in the area of MM metrics – the Maki document seems to be very good and well received. In the spirit of collaboration the PQMD HSS/MM initiative would like to connect with the Maki team. Also PQMD is working with the University of Washington on health impact metrics. Therefore the PQMD HSS/MM in conjunction the Maki team and University of Washington could assist in the development of accepted MM metrics.

5) Primary Care/Surgical/ Laboratory FocusThe literature review revealed a trend toward incorporating Surgical and Primary Care – including the WHO statement of Surgery: the neglected component of primary care. The trend supports the decision of PQMD to focus on the three MM health areas (Primary Care, Surgical and Laboratory)

6) Medical Missions support Local Health SystemsThe literature review also revealed that MM thought leaders seem to also focus on sustainability and support for local health systems. Again this support the overall direction of the PQMD Initiative.

So overall the results of the literature review seems to provide support and substantiation for the PQMD Health System Strengthening/Medical Mission initiative.

Commentary / Need for additional researchThe literature review should also incorporate addition articles/documents as they are published.

Plus there are still many unknowns and perceptions that need to be confirmed. For example there are a number of important dynamics that need to be better understood – including:

1) It appears that there is a small close knit group of experts that are the thought leaders in the area of medical missions

2) There also seems to limited number of large sophisticated organizations which have quality practices and procedure in place – but the majority of medical mission organizations are smaller and likely have less quality processes.

3) Then there are motivational factors that may impact the dynamics of medical missions such as nationalism , religion outreach and the financial funding important MM organizations

4) Also the care should be taken regarding strong opinions with entrenched attitudes and organizational self-interest

PQMD should be very careful and systematic in the development of the HSS/MM initiative with respect to these dynamics. It is also expected that personal relationship building will be a very important part of the PQMD medical mission initiative – especially as it pertains recruiting key individuals and experts to HSS/MM. Overall political sensitivity and diplomacy will be very important for the long-term success of the PQMD HSS/MM Initiative.

Note: As a personal observation - the dynamics of the PQMD Medical Mission Initiative seems to be very similar to the development activities involved with the formation of PQMD and product donations standards in 1997-2000. Therefore, it may be helpful review the early events of PQMD to help provide insight into the development of the PQMD HSS/MM Initiative.

List of References

The following is a list of References as of July 13, 2016. Many other articles/documents were reviewed by not included in this reference list due to lack of quality or relevance to the subject. Additional articles may be added as more are published or obtained. Please view this but as good starting list.

Abenavoli, F. M. (2009). A new approach for humanitarian missions. Plastic Reconstructive Surgery, 124(6), 461e-462e.

Alam, K., Ahmed, S. (2010). Cost Recovery of NGO Primary Health Facilities: A Case Study in Bangladesh, BioMed Central 8(12).

Aliu O., Corlew S., Heisler M., Pannucci C., Chung K., (2014) Build Surgical Capacity in Low Research Countries: A qualitative Analysis of Task Shifting from Surgeon Volunteer Perspective Ann Plast Surg. 2014 January; 72(1) 108-112 DOI 10.1097 / SAP. 0b013e31826aefc7

Ambrose J., (2016) Evaluating Community Dependence on Short-Term International Medical Clinics: A Cross-Sectional Study in Masatepe Nicaragua. Kent State University PhD Thesis. https://etd.ohiolink.edu/!etd.send_file?accession=ksuhonors1463133502&disposition=inline

AmeriCares – Medical Outreach Best Practice Framework – 2013 Literature Review – Review of online survey. AmeriCares Website – June 13, 2016http://medicaloutreach.americares.org/wp-content/uploads/Americares-MedOutreachPracticesSurvey-Final.pdf

Arcaya, M., Arcaya, A., Subramanian, S. (2015). Inequalities in health: definitions, concepts, and theories. Global Health Action 8, 27106.

Aronson Funtes, L. (2009). Interviewing Clients Across Cultures: A Practitioners Guide. The Guilford Press, New York, NY.

Asgary R, Junck E. New trends of short-term humanitarian medical volunteerism: professional and ethical considerations. J Med Ethics. 2012 Dec 12.

Aziz SR, Ziccardi VB, Chuang SK. Survey of residents who have participated in humanitarian medical missions. J Oral Maxillofac Surg. 2012 Feb;70(2):e147-57

Baker, J., B., Lin, L. (2006). The determinants of primary health care utilization: a comparison of three rural clinics in Southern Honduras. GeoJournal, 66, 295- 310. 217

Bangura, S., Kitabire, D., Powell, R. (2000). IMF Working Paper: External Dept. Management in Low-Income Countries. International Monetary Fund WP/00/196.

Barnighausen T, Bloom D (2009) Financial incentives for return of service in underserved area: A Systematic Review BMC Health Services Research

Baxter, P., Jack, S. (2008). Qualitative case study methodology: study design and implementation for novice researchers. The Qualitative Report, 13(4), 544-559.

Beatty, M., Hinchey, P. P., & Maddox, R. R. (2007). Thinking globally. Savannah facility has a "sister-hospital" partnership with a Guatemalan organization. Health Progress, 88(6), 78-81.

Becerra, F., Cuervo, L.,G. (2010). Health Services in Latin America, Lancet 375, 120. Berry, N. (2014). Did we do good? NGOs, conflicts of interest and the evaluation of short-term medical mission work in Sololá, Guatemala. Social Sciences & Medicine 120, 344-351.

Bermudez L., Trost K., Ayala R., (2013) Investing in Surgical Outcomes Auditing Systems Hinawi Publishing Corporation Plastic Surgery International Volume 2013 Article ID 671786 6 pages DOI 10.1155/2013/671786

Berti, P.,R., Mildon, A., Siekmans, K., Main, B., MacDonald, C. (2010). An Adequacy Evaluation of a Ten Year, Four Country Nutrition and Health Program. International Journal of Epidemiology 39, 613-629.

Bertram M., Heravi M., (2007) Project Report – A novel resource for underprivileged health support: Community Medical Outreach Rural and Remote Health (internet) 2007 7: 668

Bido J., Singer SJ., Portela D., Ghazinouri R., Driscoll DA., Alcantara A., Aggouras BM., Thornhill TS., Katz JN., (2015) Sustainability assessment of a short-term international medical mission. J Bone Joint Surg Am 2015 June 3: 97(11); 944-9 DOI 10.2106/JBJS. N. 01119

Bhatia, M., Rifkin, M. (2010). A renewed focus on primary health care: revitalize or reframe? Globalization and Health, 6(13), 6-13. 218

Blas, E., Gilson, L., Kelly, M., P., Labonte, R., Lapitan, J., Muntaner, C. (2008). Addressing the social determinants of health inequalities: what can the state and civil society do? The Lancet, 372. 1684-1689.

Brown, D. A., Fairclough, J. L., & Ferrill, M. J. (2012). Planning a pharmacy-led medical mission trip, part 4: an exploratory study of student experiences. Ann Pharmacothery, 46(9), 1250-1255.

Bolles K., Speraw C., Berggren G., Lafontant J., (2002) Ti Foyer (health) community –based nutrition activities informed by the positive deviance approach in Leogane, Haiti: A programmatic description Food and Nutrition Bulletin Vol 23, No 4 (supplement) 202 The United Nations University

Breman J., Bridbord K., Kupfer L., Glass R., (2011) Global Health: The Fogarty International Center, National Institutes of Health: Vision and Mission, Programs, and Accomplishments Infct Dis Clin North Am 2011 September; 25(3); 511-536. DOL: 10.1016/j.ide.2011.06.003

Bryce J, Gilroy K, Jones G, Hazel E, Black RE, Victora CG. The Accelerated Child Survival and Development programme in West Africa: a retrospective evaluation. The Lancet (375), 572-582.

Busse H., Azazh A., Teklu S., Tupesis J., Woldetsadik A., Wubben R., Tefera G., (2013) Creating Change Through Collaboration: A Twinning Partnership to Strenghthen Medicine at Addis Ababa University/Tikur Anbessa Specialized Hospital – A Model for International Medical Education Partnership Academic Emergency Medicine December 2013 Vol 20 No 12 DOI; 10.1111/acem. 12265 ISSN 1069-6563

Caldron P., Impens A., Pavlova M. Groot W., (2015) A systematic review of social, economic and diplomatic aspects of short-term medical missions. BMC Health Services Research (2015) 15:380 DOI 10.1866/s 12913-01500980-3

Campbell A., Sullivan M., Sherman R., & Magee, W. P. (2011). The medical mission and modern cultural competency training. J Am College of Surgeons, 212(1), 124-129. 219

Campbell A., Sherman R., Magee WP., (2010) The role of humanitarian mission in modern surgical training Plast Reconstr Surg 2010 Jul: 126 (1) 295-302 DOI 10.1097/PRS.ob013e318dab618

Canadian International Development Platform (2015). Canada’s Foreign Aid Retrieved July 3, 2015 fromhttp://cidpnsi.ca/canadas-foreign-aid-2012-2/

Carden, F. (2010). Retrospective evaluation of UNICEF’s ASCD programme. Lancet 375, 1521. 220 Carroll, T.F. (1992). Intermediary NGOs: The supporting link in grassroots development. West Hartford, CT: Kumarian Press.

Catholic Health Association – Short Term Medical Mission TripsRecommendation for Practice 2015

https://www.chausa.org/docs/default-source/international-outreach/short_term_medical_mission_recommendations_for_practice.pdf?sfvrsn=0

Chapin, E., Doocy, S. (2010). International short-term medical service trips: guidelines from the literature and perspectives from the field. World Health Population 12(2), 43-53.

Chavez, F., Bender, A., Gastaldo, D. (2012). Global Health (Chapter 31). In L. Stamler & L. Yiu (Eds). Community Health Nursing: A Canadian Perspective (3rd ed.). Pearson Education Canada, 480-491. He Gambia’s New Community-Bases Medical Program MECICC Review January 2012 Vol 14 No 1

Chen, A.T., Pedtke, A., Kobs, J.K., Edwards, G.S., Coughlin, R.R., Gosselin, R.A. (2012). Volunteer orthopedic surgical trips in Nicaragua: a Cost-effectiveness evaluation. World Journal of Surgery, 36(12), 2802-2808.

Chiu, Y., Weng, Y., Chen, C., Yang, C., Lee, M. (2014). Perceptions of Efficiency of Short-Term Medical Aid Missions Among Key Groups of Health Professionals. Health Services Research and Practice 37(3), 379-393.

Chiu YW, Weng YH, Chen CF, Yang CY, Chiou HY, Lee ML (2012) . A comparative study of Taiwan’s short-term medical missions to the South Pacific and Central America. BMC Intl Health Hum Rights. 2012 Dec 27; 12:37.

Citrin D., (2010) The Anatomy of Ephemeral Health Care: “Health Camps” and Short-term Medical Voluntourism in Remote Nepal. Studies in Nepali History and Society 15 (1) 27-72 June 2010 Mandala Book Point

College of Physicians and Surgeons (CPSO) (2008). The Practice Guide: Medical and Professionalism and College Policies retrieved June 8, 2013 from http://www.cpso.on.ca/uploadedFiles/policies/guides/PracticeGuideExtract_08.pdf 221

Corno A., (2016) Paediactirc and congenital cardiac surgery in emerging economies: Surgical ‘safari’ versus educational programmes Interacrive Cardiovascular and Thoracic Surgery (2016) 163-167 DOI; 10.1093/icvts/ivw069 Advance Access Publication 21 March 2016

Council on Foreign Relations – The Challenge of Global Health Governance

http://ec.europa.eu/health/eu_world/docs/ev_20111111_rd01_en.pdf

Cristia, J., García Prado, A., Peluffo, C. (2015). The Impact of Contracting in and Contracting out Basic Health Services: The Guatemalan Experience. World Development 70, 215-227.

Cueto M. (2004). The origins of primary health care and selective primary health care. American Journal of Public Health 94(11), 1864–74.

Crump JA and J Sugarman. 2008. Ethical Considerations for Short-Term Experiences by Trainees in Global Health. Journal of the American Medical Association, Vol. 300(12): 1456-1458.

Crump JA, J Sugarman, and the Working Group on Ethics and Guidelines for Global Health Training (WEIGHT). 2010. Ethics and Best Practice Guidelines for Training Experiences in Global Health. American Journal of Tropical Medical Hygiene, Vol. 83(6): 1178-

Cunningham C., Sanchez J., Heller D., Sohler N., (2007) Assessment of Medical Outreach Program to Improve Access to HIV Care Amoung Marginalized Individuals American Journal of Public Health Oct 2007 vol 97 No 10

Dacso M., Chandra A., Friedman H., (2013) Adopting an ethical approach to global health training: the evolution of the Botswana- University of Pennsylvania partnership Acad Med 2013 Nov; 88(11) 1646-50 DOI 10.1097/ACM. Ob 013e3182a71514

Dainton C., Chu C., (2014) Symptom clusters on primary care medical service trips in five regions in Latin America Journal of Epidemiology and Global Health (2015) 5, 259-

Daniels K., Sanders D., Daviaud E., Doheryt T., (2015) Valuing and Sustaining (or Not) the Ability 264of Volunteer Community Health Workers to Deliever Integrated Community Case Management in Northern Ghana: A Qualitative Study PLOS ONE DOI: 10.1371/journal .pone 0126322 June 16, 2015

Davis, M, C., Than, K, D., Garton, H, J. (2014). Cost Effectiveness of a Short-Term Pediatric Neurosurgical Brigade to Guatemala. World Neurosurgery 82 (6), 974- 979.

DeCamp, M. (2007). Scrutinizing Global Short-Term Medical Outcomes. Hastings Centre Report 37(6), 21-23.

DeCamp M. Ethical review of global short-term medical volunteerism. HEC Forum. 2011 Jun; 23(2):91-103. Dickson M, Dickson GG. Volunteering: beyond an act of charity. J Can Dent Assoc. 2005 Dec; 71(11):865-9.

DeCamp, M., Enumah, S., O’Neill, D., Sugarman, J. (2014). Perceptions of a short-term medical programme in the Dominican Republic: Voice of care recipients. Global Public Health 9 (4), 411-425.

DeCamp, M., Rodriguez, J., Hecht, S., Barry, M., Sugarman, J. (2013). An ethics curriculum for short-term global health trainees. Globalization and Health, 9(5).

Dempsey K., Ghazinouri R., Diez D., Alcantara L., Beagan C., Aggouras B., Hoagland M., Thornhill T., Katz J., (2013) Enhancing the quality of international orthopedic medical mission trips using blue distinction criteria for knee and hip replacement BMC Musculoskeletal Disorders 2013 14: 274

DeVos, P., De Ceukelaire, W., Bonet, M., Van der Stuyft, P. (2007). Cuba’s International Cooperation in Health: An Overview. International Journal of Health Services 37(4), 761-776. 222

Dienye P., Dient-Spiff K., Chukwuma N., (2014) Practice of Anaesthesia and Surgery in a Rural Clinic: Meeting the Challenge Turkish Journal of Family Medicine and Primary Care Vol 8No 2 July 2014

Dmytraczenko, T., Almeida, G. (2015). Towards Universal Health Coverage & Equity in Latin American and the Caribbean: Evidence from Selected Countries. International Bank for Reconstruction and Development: The World Bank. Washington, D.C.

Dowell J, Merrylees N. (2009). Electives: isn't it time for a change? Medical Education 43(2), 121-126.

Dupuis, C. (2004). Humanitarian missions in the third world: a polite dissent. Plastics Reconstructive Surgery, 113(1), 433-435.

Eberlin KR, Zaleski KL, Snyder HD, Hamdan US; Medical Missions for Children. Quality assurance guidelines for surgical outreach programs: a 20-year experience. Cleft Palate Craniofac J. 2008 May; 45(3):246-55.

Elliot C., Toomey R., Goodman B., Barbosa P., (2012) Transformative Learning: Emphthy and Multicultural Awareness in Podiatric Education Journal of the American Podiatric Medical Association Vol 102 No 1 January/February 2012

Emanuel EJ, Wendler D, Killen J, Grady C. What makes clinical research in developing countries ethical? The benchmarks of ethical research. J Infect Dis. 2004 Mar 1; 189(5):930-7.

Farmer P, Kim J. (2008). Surgery and Global Health: A View from Beyond the OR. World Journal of Surgery, 32(4), 533-536.

Filmer, D., Hammer, J., S., Pritchett, L., H. (2000). Weak links in the chain: A diagnosis of health policy in poor countries. The World Bank Research Observer, 15(2), 199-224.

Filmer, D., Hammer, J.S., Pritchett, L., H. (2002). Weak Links in the Chain II: A Prescription for Health Policy in Poor Countries. The World Bank Research Observer 17(1), 47-66. 223

Gainor, B., J., Epps, C., H. (2002). Volunteerism in Orthopaedics. Issue 396 of Clinical Orthopaedics and related research. Lippincott Williams &Wilkins Government of Canada (2015). Canada-Honduras Relations Retrieved June 12, 2015

Gascon M., (2011) Traditional and Modern Practices Enhance Health Knowledge of the Bagobo Tribe Asian Journal of Health Vol 1 No 1 Januray 2001 ISS: 2094-9243 pp 143-159

Giordana J., Hutchinson P., Benedicker R., (2009) Cultural Sustainabiilty and Medicine in the Twenty-first Century. Re-grounding the Focus of Medicine Amidst the Current “Global Systemic Shift” and the Forces of the Market: Elements for a Contemporary Social Philosophy of Medicine International Journal of Politics, Culture and Society March 2010 Vol 23 Issue 1 pp 29-41

Goecke M., Kanashiriro J., Kyamanywa P., Hollaar G., (2008) Using Can MEDS to guide international health electives: an enriching experience in Uganda defied for a Canadian surgery resident Can J. Surg Vol 51 No 4 August 2008

Graham, H. (2007). Unequal Lives Health and Socioeconomic Inequalities. Berkshire, England: McGraw-Hill Education.

Green, T., Green, H., Scandlyn, J., Kestler, A. (2009). Perceptions of short-term medical volunteer work a qualitative study in Guatemala. Globalization and Health 5(4), 1-13. 224

Green, S., S., Comer, L., Elliott, L. Neubrander,J. (2011). Exploring the value of an international service-learning experience in Honduras. Nursing Education Perspective, 32(5), 302-307.

Green, T., Green, H., Scandlyn, J., Kestler, A. (2009). Perceptions of short-term medical volunteer work: a qualitative study in Guatemala. Globalization and Health, 5(4). Greenhalgh, T. (2007). Primary health care: theory and practice. Massachusetts, USA: BMJ Publishing Group Inc.

Gutnik L., Dieleman J., Dare A., Ramos M., Riviello R., Meara J., Yarmey G., Shrime M., Funding allocation to surgery in low and middle-income countries: a tretropective analysis of contributions from the USA BMJ Open 2015 5;5:e008780. DOI 10.1136/bmjopen-2015-008780

Haskell A., Rovinsky D., Brown H., Coughlin R.R. (2002). The University of California San Francisco Orthopedic Residency Elective in International Volunteerism. Clinical Orthopaedics and Related Research, 1(396), 12-18.

Hancock, D., R., Algozzine, B. (2011). Doing case study research: A practical guide for beginning researchers. (2nd ed.), New York, NY: Teachers College Press.

Hanson, L., Harms, S., Plamondon, K. (2011). Undergraduate international medical elective: Some ethical and pedagogical considerations. Journal of Student International Education 15 171-185. 225 Harrowing, J. N., Mill, J. (2010). Moral Distress among Ugandan nurses providing HIV care: A Critical Ethnography. International Journal of Nursing Studies 47, 723- 731.

Health and Care Professions Council (2013). Health Regulation Worldwide. Retrieved August 12, 2013 fromhttp://www.healthregulation.org/

Heck JE, Bazemore A, Diller P. The shoulder to shoulder model-channeling medical volunteerism toward sustainable health change. Fam Med. 2007 Oct;39(9):644-50.

Henderson K., (2007) Lessons from working oversees Anesthesia 2007 62 (suppl 1) pages 113-117The Association of Anesthetists of Great Britain and Ireland

Heredia, N., Luarell, A.,C., Feo, O., Noronha, J., González-Guzmán, R., Torres-Tovar, M. (2015). The Right to Health: What Model for Latin America. Lancet 385, e34- 37.

Hershberger, A. (2001). The delicate dance: a case study of relationships between Nicaraguan health nongovernmental organizations, communities served, donor agencies, and the Ministry of Heal