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Executive Brief

U.S.-based Catholic health ministries partner beyond our country's borders to provide much-needed health care service to families and communities in low-income countries. But in so doing, are our best intentions providing help and hope to those whom we want to serve? Do they also serve our ministry's need for formation? What, exactly, do most trips include, and what financial and human resources are involved? These are questions CHA raised with a 2014 research project aimed at getting a picture of current practices in short-term medical mission trips, from the U.S. perspective.

What follows is an executive brief of the newly-released report, Short-Term Medical Mission Trips: Phase I Research Findings—Practices & Perspectives of U.S. Partners, which shares high-level research results, recommendations for practice and questions to consider in relation to short-term medical mission trips. Knowing the resources it takes to conduct these trips, we hope to help CHA members and other participants have the highest positive impact possible.

The full report and additional resources are available at www.chausa.org/international. Please feel free to contact me at [email protected] to share some of your practices or to gain additional information.

— Bruce Compton

Executive Summary

BACKGROUND
Over the past two decades, the number of short-term international mission trips for the provision of health services has dramatically increased and Catholic health care has participated in this growth. While these experiences provide an opportunity for Catholic health care to continue its mission of reaching out to those persons who are poor, sick and vulnerable, there are consistent concerns about their value and effectiveness. Considering the significant human and economic investment in health service trips, it is essential to gain a better understanding of these activities and to consider how they can provide the maximum benefit for all involved.

The Catholic Health Association (CHA) is frequently asked for best practices and/or orientation materials or other guidance that can be used by groups conducting short-term medical mission trips. Admittedly, there is information available, but not much specific to health care or that connects this work to Catholic social teaching and our commitments to human dignity, justice and equality.

To gain a greater understanding of what is actually being sponsored by Catholic health ministry, or that member associates are participating in, CHA launched a research study of short-term medical mission trips in 2014. The goal: to create a snapshot of current practices and to share recommendations for increasing the effectiveness of short-term medical mission trips.

This document is an Executive Brief of the report "Short-Term Medical Mission Trips: Phase I Research Findings — Practices & Perspectives of U.S. Partners." To see the full report, go to www.chausa.org/international.

METHOD
This study's initial goal was to gather as much data as possible on current and ideal practices. CHA distributed an online survey to Catholic hospitals and health systems to reach those who had participated in or had overseen a short-term medical mission, but it was open to anyone who chose to respond. With over 500 respondents, this is likely the largest existing set of data on short-term medical missions. The survey was followed by 18 in-depth interviews with a cross-section of the survey respondents.

FINDINGS
Survey participants collectively had been on a minimum of 949 trips over the past five years. The "most recent" trips reported included approximately 2,300 volunteers traveling to 45 countries at an estimated cost of $3.45 million. Organizers estimated that about one-fourth of this amount is spent in the host countries.

CHA member organizations sponsored about 40 percent of these trips. Many CHA member hospitals and health systems do not directly sponsor medical mission trips, although they may provide indirect support.

Overall, participants expressed great satisfaction with mission trips. They considered them to be extremely valuable for volunteers (91 percent), for Catholic health care (78 percent), and for host communities (75 percent). Responses to the question about value to host communities was the only one of the three which elicited strong reservations, e.g., medical missions are only valuable if designed well, and there are concerns about increasing dependency and causing harm.

The greatest challenges to creating effective medical mission trips were identified as funding, sustainability and coordination of effort. There were also a number of areas in which there were significant gaps between the characteristics of "actual" and "ideal" trips. They include:

Selection of volunteers Most trips accept almost every person who applies. Organizers strongly preferred greater selectivity of volunteers. They expressed a desire to include only those who work well in teams and are willing to learn from the host community and reported their wish to exclude those who are non-compliant with the rules or who have physical or mental health issues.

Length and content of orientation When there is an orientation, it typically lasts one to two hours; participants ideally want orientation to last half a day. Preparation usually emphasizes information about flights, vaccinations and packing. Volunteers desire much more preparation in cultural competence, country history, language and specific skills needed for the trip. Volunteers also want to have preparation for the activities they will be engaged in and personal and group reflection about the trip.

Length of trip One third of participants' trips lasted one week or less; most participants believe that trips should last longer.

Role of partner The importance of having an effective and trusted partnership in the host community emerged from the study. The most frequent role of partners is assisting with logistics and services. Participants expressed a preference for partners to be more centrally involved in establishing goals.

Evaluation The major focus of evaluation, when it is done, is on the volunteers' experience and the logistics of the trip itself. There is hardly any systematic assessment of the impact of medical mission trips for host communities. Evidence of impact is primarily anecdotal.

The report concludes with recommendations in each of these areas and others that emerged from the study.

A FINAL NOTE
This investigation, by focusing on Americans involved in medical missions, does not allow us to document health benefits to poor communities who host medical missions —presumably the most important measure of their value. But it does give us important insights into current practices and perceptions of those in the U.S. who are engaged in short-term medical mission work. Given Catholic health care's global network and its shared sense of mission, it is uniquely positioned to be a leader in setting a standard for short-term international health volunteer efforts more broadly.

Recommendations for Practice

PARTNERSHIPS

1. Identify partners who are reliable and respected advocates for their communities and have a continuous presence. A relationship of equality, mutual respect and cooperation takes time to nurture and formalize, but is essential to sustainability.

2. Develop a memorandum of understanding to define each partner's responsibilities, tasks and benefits. Review and update regularly.

3. Identify several people within your organization who can be points of contact for host communities. The long-term success of trips may require someone other than the primary organizer, whose position within your organization can easily change. Partnership must be an institutional commitment rather than an individual one.

FUNDING EFFORTS
If the hospital or health system provides material or financial support, it should consider how to target its limited resources to fewer, well-run efforts rather than spreading resources across many projects with variable levels of success. This targeted support includes paid time off for employees, medication, supplies and staff time. The institution ought to ensure that the group facilitating the trip has similar goals as the institution itself regarding volunteer formation and host community health improvement.

ORIENTATION OF VOLUNTEERS

1. Include topics in orientation of volunteers that may not seem immediately necessary but will prepare them for the experience, including historical and cultural information about the host country, unique cultural differences and an overview of the local health system.

2. Include personal and group reflection on the role of volunteers that is designed to promote humility and realistic expectations. Prepare volunteers for the tasks they will be carrying out and for the importance of collaboration within their team and with host community staff.

3. Require, insofar as possible, a real commitment to orientation activities. This will ideally be at least a half day of time, keeping in mind that it is not unrealistic for a group on a trip lasting more than one week to give four hours to prepare themselves for 168 hours of in-country activity.

4. Ask repeat volunteers to go through the same orientation as everyone else, even if they express a feeling that it is not necessary for them. Their experiences and reflections benefit new volunteers. Their presence adds to the group cohesiveness that is beneficial when your group arrives in country. And they can always be challenged to consider ways in which this trip is not just a recapitulation of old trips, but is a unique experience that carries its own challenges and opportunities.

ACTIVITIES UNDERTAKEN

1. Determine the activities of the mission trip through a collaborative process aimed at identifying community needs and volunteer ability. This may take more time than you anticipate and will likely require one or more trips to the host community by those skilled in community assessment before sending a larger group of volunteers.

2. Since all activities should already be mutually agreed upon by volunteers and the host community, regularly confer with the hosts about how they perceive activities are going and in what ways the activities can be improved during your stay. They will often be reticent to offer direct criticism, so you should find ways for them to offer suggestions along the way.

3. Consider which tasks volunteers are doing that can be carried out by the host community. Even though your volunteers may expect to take medical histories or run health education sessions, if possible, these activities can be done by local volunteers, thus building capacity during your short time in country.

4. Give considerable thought as to how your activities might be causing unintended harm to the host community. Ensure that local health providers are seen as partners or leaders in your effort. Ask clinicians to consider complications that may arise from medications and procedures and create a plan of action with local providers. For example, potent medications given to a family with small children without childproof containers can be more harmful than no medication at all. Such unintended consequences are best understood through honest conversation with local health providers. In short-term medical missions, something can actually be worse than nothing.

EVALUATION

1. A continuous presence (of your group or your association with a local organization) makes it more likely to be able to assess the impact of mission trips on communities. Develop metrics for effectiveness and track data after each trip. These should include population-level data and impact on the local health system. Anecdotes and informal feedback are insufficient to document effectiveness, and volunteers are not a good source for affirming the value of a trip.

2. Consider the feedback from host communities when evaluating the trip, but do not count on "thank you" or requests to return as proof of your effectiveness. Very often there are benefits to host communities other than improving the community's overall health: the relationships of solidarity built between hosts and volunteers, single medical interventions and ancillary income from your trip (donations to the organization, your group paying for lodging, etc.), to name a few. Therefore, positive feedback from communities is not always for the reasons organizers assume.

3. The true value to volunteers should not be assumed and should be evaluated. Much like the evaluation of impact on host communities, this should be more than anecdotal. This is particularly challenging after volunteers return from the host country. Nevertheless, gathering feedback from volunteers on the formative elements of the trip is best done with some time between the experience itself and the evaluation.

IMPROVING SUSTAINABILITY

1. Longer stays and more frequent returns to the same place make it possible for communities to know what to expect, develop relationships and have continuity of care, especially important with the rise of non-communicable diseases in most poor countries.

2. Working with communities to identify and address underlying causes of ill health increases the chances of impact.

3. Consider the ways in which your trip's activities can be integrated into and improve the capacity of the continuous operation of the local health system. Doing so has the potential to strengthen the local health system and the local providers, making it more likely to achieve both short-term and long-term goals of the community.

THE IMPORTANCE OF LANGUAGE

1. Given the power of language, it is important to describe mission work with appropriate terminology. If we describe the host community as "recipients" or "beneficiaries," we inadvertently undermine the goal of a mutual partnership, reinforce stereotypes of superiority and inferiority, and make assumptions about whether people are truly benefiting. They are best described as "hosts" or "partners."

2. Although most groups characterize trips as "medical missions," "surgical brigades" or something similar, there are instances where they are described as a "volunteer vacation" or "surgical safari." The language used to describe the trip sets expectations for volunteers. The formative element for volunteers suggests the need for mission-oriented language as opposed to describing it as a vacation or adventure.

SELECTION AND RECRUITMENT OF VOLUNTEERS

1. The recruitment of volunteers should take place only after the host community assessment has been completed. Then, the skills needed for the key activities can be identified and sought by trip organizers.

2. Volunteers should be more carefully screened for adaptability to the medical mission trip experience; in particular, their ability to cooperate in a team and respect the host community members, and for skills needed by host communities. This may be possible only with greater screening procedures, such as interviews of volunteer applicants. Although technical skills are often necessary, they are only part of what makes a successful volunteer.

3. Because trips are understood to be formative experiences for the volunteers as much as they are improving the health of host communities, organizers should be clear with volunteers about this reality and should look for volunteers who are open to being formed by the experience.

IMPORTANT QUESTIONS TO ASK ABOUT MEDICAL MISSIONS
If you are a hospital or health system administrator being asked to launch or support a medical mission, we recommend that you ask whether it is integrated into a larger strategic vision for the hospital or health system.

Regardless of whether you are organizing a trip, considering volunteering on one, or have a position of responsibility in Catholic health where you may be supervising or supporting others who go on missions, these recommendations lead us to suggest that you ask some hard questions before proceeding with participation.

Partnerships: Have we established a relationship with local leaders, including local medical staff, leaders and community members?

What kind of process have we used to determine shared goals? Have we taken the time to identify needs as defined by the host community and to establish trust?

Recruitment and selection of volunteers: What kind of qualities and skills do we (organizers and partners) believe to be important in volunteers? Are these determined in collaboration with the host community once the goals have been mutually agreed upon? Are we doing enough to screen potential volunteers to be sure they bring what is needed?

How can we best engage those in the hospital/health system who can't travel to be involved in the formation of volunteers and the health of host communities?

Orientation for volunteers: Is there an effective pre-trip orientation, lasting half a day or more, that includes:

• Trip logistics and in-country activities, including why the activities volunteers will do have been chosen.
• History and culture of the host country, including an understanding of political and economic sources of poverty and need and cultural differences that may impact delivery of health services.
• Personal and group reflection on motivation and expectations.
• Learning of key phrases in local language.

In-country activities: Are there activities where volunteers can build capacity or transfer skills to local providers rather than performing tasks themselves? Again, are the volunteers trained in the skills needed and in the capacity to train others?

Might there be unintended negative consequences to the activities volunteers are engaging in? For example, are they bringing medications that will be available just once with no continuity of care? Will they be providing surgical interventions or chronic disease treatment without adequate follow-up? Will they be teaching lessons around health practices that are inappropriate for the setting?

Evaluation: Is there an evaluation of the impact on the lives and professional work of the volunteers, both soon after the trip and over the course of time?

Is there an evaluation of the impact on the health of the host community? Do we have an understanding of success that is shared with the host community? Is the in-country partner involved in determining the best metrics for success and are they trained to collect the necessary data if it does not have those resources already?

Are decisions about future trips based on the results of evaluation?

Conclusions
This report is intended to start a much broader conversation around short-term medical mission trips. Given Catholic health care's global network and its shared sense of mission, it is uniquely positioned to be a leader in setting a standard for international health volunteer efforts.

We are keenly aware that trips are very unique entities: staffing and skills of volunteers, types of in-country partners, disease burden of the host community and the mutual goals of organizations will all create a trip that cannot be specifically addressed in a report of this breadth. Therefore, the information presented here is not meant to be overly prescriptive. Nevertheless, we would be remiss if we ignored the fact that there are practices we know to be deleterious to volunteers and the host community and other practices that improve the likelihood of a trip being effective.

Based on our experience, we believe that if done properly, everyone can benefit. One concern however, is that almost everyone (91 percent) who participated in the survey agreed that medical mission trips are extremely valuable to volunteers, but a lower percentage (75 percent) is convinced that they are extremely valuable to host communities. This discrepancy tells us several things.

First, we have better evidence that short-term medical missions benefit volunteers, although even this evidence is largely anecdotal. This occurs in post-trip debriefing of volunteers and continued conversations about the impact
of trips on volunteers' lives. We do not have comparable evidence of the impact on host communities, which likely leads to more skepticism of their value.

Second, the trips may, in fact, be more valuable to volunteers than host communities. The assessment of value could be a very accurate assessment, which should lead us to consider how we promote and describe these trips. For understandable reasons, groups may be reluctant to frame them as volunteer formation instead of improving the health of host communities. Nevertheless, it would be worth reflecting on whether part of the consistent criticism of short-term medical missions might be rooted in people's perception that the trips lack honesty in their stated objectives.

The desire to identify leading practices is not just rooted in good professional practice. There is an ethical imperative that also drives the desire to improve short-term medical missions. If there are better ways to do this work and we are not intentional in pursuing them, then we are doing ourselves and the host communities a great disservice. It may not be possible to prescribe what should always be done, but it is almost certainly possible to prescribe what should never be done.

The results presented herein are only the first phase of a larger research agenda. This report provides the perspective of those participating in short-term medical missions. Yet in order to gain a more complete picture, the perspective of in-country partners and communities who are served must be more fully understood. This is an even more under-researched area than the benefit to participants
of short-term trips. And yet, it may be the most important area in order to answer how effective short-term medical mission trips truly are.

FOR MORE INFORMATION
This Executive Brief, the full report, as well as all of CHA's International Outreach resources, are available at chausa.org/international.

Copyright © 2014 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.