What Do Patients and Communities Expect of a Medical Mission?

Fig. 8.1

A conceptual framework of the expectation of a medical mission (The pillars of successful medical missions)

Quality and Safety

Quality and safety are multifaceted issues. The Institute of Medicine (IOM) has identified six aims of quality medical care [5]:

Safety: Providers must ensure that the medical care intended to benefit patients is not causing harm. This requirement is particularly applicable as many developing countries do not yet have safety standards built into their health care systems, and medical providers are often asked to practice outside of their expertise, which is both unsafe and unethical.
Effectiveness: Medical treatments must be based on scientific knowledge, and must produce beneficial, measurable results.
Patient-centered: Care must be tailored to individual patient preferences, needs, and values. Patients should have authority over their own medical care, and their input must guide clinical decision-making.
Timeliness: Patients requiring medical attention should have access to timely health care and follow-up care to avoid potentially harmful delays in treatment.
Efficiency: Quality health care avoids wasting finances, time, equipment, and energy. Efficiency maximizes the impact of global health organizations.
Equitability: The quality of medical care must be consistent across all patient types, irrespective of gender, ethnicity, socioeconomic status, and other personal characteristics. Similarly, visiting medical providers must hold themselves to the highest standards of quality care, as they would in their home countries.

Developing countries have poor economies and poor resources, which should not be a deterrent to providing quality care. Patients do wish to have quality care.

While low quality health care may be primarily a reflection of inadequate financial resources, there is evidence that quality can be enhanced in a number of ways even in the absence of additional resources [6].

Ideally, people throughout the world should gain access to quality health care. However, there are considerable challenges in resources and organization to achieve all six key components. The World Federation of Societies of Anaesthesiologists (WFSA), which was founded in 1955 aims to make available the highest standard of anesthesia to all peoples throughout the world [7, 8]. The international standards recommended by the WFSA are aimed at anesthesia professionals everywhere to improve and maintain the quality and safety of anesthesia care. For some countries, these standards have already been implemented but for many countries or different areas in the same countries, these standards may represent a future goal. Nonetheless, the goal is always the best possible care and ongoing improvement for the safe practice of anesthesia [8].

Quality health care is about getting the right care to the right patient at the right time, and achieving the best possible outcome. Although it sounds simple, quality may vary for many reasons. Advanced technologies offer the promise of improving health, increasing life span, and reducing pain and suffering. However, working in multicultural areas requires knowledge of cultural differences and beliefs. What is considered the best care in one region may not be the best in many other, even adjacent, areas. The quality issue becomes even more complicated when facing a huge patient need and demand. In many areas worldwide, there is a problem of provider volume and density. When the ratio of patients to providers is overwhelming, the need is often determined by a combination of triage and weighing of risks and benefits for each patient.

Provision of quality anesthesia care requires both human and nonhuman resources (Table 8.1). Human resources include manpower, education, knowledge, skills, and experience of both physician and non-physician anesthesia providers. In addition, the multiple disciplines involve in the various components of safety must be considered. Therefore, multidisciplinary aspects of care through team training are vital. The World Health Organization (WHO) has introduced a surgical safety checklist in 2009, as a mean to improve surgical patient safety through multidisciplinary communication. The checklist was first launched in June 2008, and has been translated into at least six languages (Table 8.2). WHO 2009 surgical checklist comprises vital checks in three phases: sign in (before starting anesthesia), time out (before starting surgery), and sign out (at the end of surgery) [9]. The use of a checklist can be locally modified to suit the individual hospital setting. Recent studies show the benefits of operating room teamwork and communication, including reductions in morbidity and mortality among surgical patients in a diverse group of hospitals [9, 10].

Table 8.1

Types of resources needed for quality and safety in anesthesia

Human resources	Nonhuman resources
• Manpower • Education/knowledge • Skills • Experiences	• Equipment/tools • Monitors • Drugs • Blood supply

Table 8.2

Three phases in the WHO surgical safety checklist [9]

Sign in: Before starting anesthesia	Time out: Before starting surgery	Sign out: At the end of surgery
• Patient identification • Surgical marked site • Allergy • Difficult airway or aspiration risk • Bleeding risk and planned intravenous fluid therapy • Readiness of anesthesia machine, medications, pulse oximeter	• Confirmation of team members • Confirmation of the patient, procedure, and incision site • Antibiotic prophylaxis within the last 60 min • Anticipated critical events to surgeon, anesthesiologist, and nursing team • Availability of essential imaging	• Confirmation of the performed procedure • Complete counts of instrument, sponge, and needles • Correct specimen labeling • Addressing any equipment problems • Key concerns for patient recovery and management

Nonhuman resources include equipments, tools, monitors, anesthetic drugs, and blood supply. Provision of these resources is as important as medical logistics to support medical missions. The logistics of pharmaceuticals, medical and surgical supplies, devices and equipments are also essential for the continuity of care. In the resource-poor setting, this issue remains challenging.

A well-developed infrastructure is necessary to manage these resources for long-term use. Well-thought out strategic plans are required to make efficient use of limited resources. Considering the health of all as interconnected and closely linked to economic forces, resources must be used with the awareness of ongoing widespread poverty, world population growth, global warming, and depletion of limited natural resources. In other words, a “global mind-set” must be emphasized [11]. Although advanced anesthesia machines and equipments have provided better care for patients, overreliance on them may cause hidden problems and dangers. Evidence shows that many operating rooms in the developing world are littered with an accumulation of well-meaning mission donations in the form of unrepaired ventilators, and anesthesia machines, often labeled with the name and date of the mission [12]. Instead of modern and high-tech anesthesia machines, a simple medical ventilator such as the Bird respirator may be more practical in an area where electricity is not widely or consistently available (Fig. 8.2).

Fig. 8.2

Bird respirator at Ramathibodi hospital in Bangkok, kept in well-functioning condition for learning and teaching purposes

In addition simpler anesthesia machines and equipment may be easier for local staffs to maintain in working order. The literature reveals that short-term medical missions have improved the lives of patients in resource-limited area, but the ability to make a meaningful and lasting effect in the developing world is difficult [12].

Ethics and Cultural Relevance

Behavioral and cultural differences are significant barriers when working in different locations worldwide. Many models have been developed to cope with this problem. Rassiwala et al. reported two models of educational engagement: a 1-week program and a 4-week program for medical students [3]. Two physicians from the same university supervised the short program, while the longer program was coordinated by the nonprofit organization that worked with local health care providers [3]. A longer duration program provided more time to develop good rapport, language and ethnic learning that bridges the cultural and ethical gaps between visiting medical students and the local population. The model of a longer duration of global health educational program helped medical students to incorporate their knowledge to better suit a resource-limited setting and also to build a better patient-provider bond. The same positive impact in terms of better collaboration and understanding of a cultural and social context was evident by senior physicians who may be able to stay in a place for long-term missions [13].

Despite good intentions, many international medical missions are unsuccessful. One of the major problems comes from cultural differences. Regardless of race or location, communication should proceed in a caring, and respectful manner to reduce culture-related communication problems, not only to the patients but also to local physicians on the basis of respect for their skills, knowledge, and traditions [13, 14]. Carrese et al. studied strategies for discussing negative information with Navajo patients in 34 Navajo informants [15]. There were three categories of informants: patients, traditional healers, and Western biomedical health care providers. The study suggested a four-stage approach to facilitate the bridging of cultural differences. The first stage is a patient assessment to assess the willingness and appropriate timing for any discussion. The next step is a preparation, which entails cultivating a trusting relationship, the involvement of family members, and facilitating the involvement of traditional healers if needed. The third stage is communication in a caring, kind, and respectful manner. Finally, the follow-through should be completed for the continuation of care.

International Collaboration and Sustainable Quality Health Care

Several issues are essential to maintain sustainable health care through international collaboration;

Education: in-country vs. oversea training programs;

Service: short-term vs. long-term and

Research: routine-to-research methodology

Education

In the developing world, education systems are poorly developed or nonexistent. Many peoples are uneducated and carry on with the traditional “cures” they received for generations when they were sick. To maintain good health free from many diseases, good hygiene is necessary—a concept that is also foreign to many in underdeveloped countries.

But even educated people in these countries often have very low expectations of the health care system—they experience cycles of health crises and do not maintain good health. An environment in health care must be created so that these people can also look for care when they need it, and not wait for the situation to become acute or critical. Most of the time these educated mass also do not trust the modern health care system and prefer to be treated by local medicine men. For example, Dhami Jhakri are the Nepalese words for shamans who are local healers and consulted by the local community. They are found in Nepal, parts of India, not only in remote villages but also in cities. Similar mediums, who practice often by spirit possession, are prevalent in other groups and tribes.

Poverty and lack of education, along with other social determinants, are proven barriers to health care. Various measures of health quality, including low life expectancies and high mortality rates, correlate to low levels of education [16]. People living in poverty usually have not been educated as to when, why, and where to access health care. Many mistakenly believe that their affliction is irreversible and permanent or the result of some wrongdoing on their part or the influences of evil spirits, and they are unaware of medical treatments that can treat or cure their condition. Additionally, general public health education is lacking, such as knowledge of proper hygiene and water treatment. It is the role of global health organizations to fill these educational gaps. By training health workers and community members to raise awareness about good health practices and opportunities to access medical care, global health organizations can produce far-reaching positive results.

The developed world needs to be educated and made more aware of poverty-induced health crises across the globe. Though general health education is readily available in affluent countries, education and advocacy about poverty-induced health crises throughout the world are necessary to spur developed nations to action.

Strasser described it well: “Despite the huge differences between developing and developed countries, access is the major issue in rural health around the world. Even in the countries where the majority of the population lives in rural areas, the resources are concentrated in the cities. All countries have difficulties with transport and communication, and they all face the challenge of shortages of doctors and other health professionals in rural and remote areas. Many rural people are caught in the poverty–ill health–low productivity downward spiral, particularly in developing countries.” [17]

An earlier paper by Yancey reported “Health care providers are reminded at intervals that rich and poor, educated and illiterate people react similarly to excellent, considerate health services. Practice does not make for perfection in medicine; only excellent practice permits a close approximation to perfection. Poor people know of the presence and accessibility of the public teaching hospital in their community, yet they report to the hospital later than the higher income, private hospital individuals for care” [18]

And finally Clark reporting on volunteers in Ghana wrote: “Even though people are generally poor they still want to preserve their dignity. Valuable/expensive things offered on a silver platter tend to lose their value and have the tendency to be abused. Thus it is always advisable to let people bear some responsibility. This is why some communities have to pay a token fee for some of the services or medications. No matter how meager a fee paid, it is enough to let one value whatever is offered. If something very expensive is being offered for free, the notion is that it is meant to be thrown away; and that is why it is being given to them. They may even feel belittled by the totally free offer.” [19]

Indeed, global health disparities and inequitable access to health care in developing countries should be an ongoing concern for many if not all physicians [20].

Thus evidence and research underscore that education is the key to sustainable changes in developing countries. Bidirectional education between low and high-resource countries can be beneficial to both sides. Low-resource countries gain knowledge, advanced clinical skills, and infrastructure organizing skill to meet their local needs. Students and faculty from high-resource countries also gain medical knowledge, clinical skills, cultural sensitivity, adaptability, flexibility and have more appreciation for public health and socioeconomic factors. The knowledge and experiences gained from working in low-resource countries can have long lasting beneficial effects on their career paths [7, 21, 22].

The World Federation of Societies of Anaesthesiologists (WFSA) has provided training opportunities in many areas around the world, both in-country training programs and overseas training programs. Candidates for oversea training must commit to return home to practice. The main advantage of overseas training program is the opportunity for the trainee to see the system and infrastructure support of anesthesia from the inside. The graduates can use knowledge and experience to organize infrastructures, improve anesthesia practice, and even become professional leaders in their homelands. However, local investments for infrastructure support and continuing education, as well as political commitments are essential to attract physicians and non-physician staff and retain those trained anesthesia providers in the areas of need. Studies reveal barriers to recruitment and retention of anesthesia providers that include poor working environment and limited appeal of health care jobs. These critical issues must be acknowledged and remedied in order to reduce the complex problem of “brain drain” [23]. In low-income and middle-income countries, well trained anesthesia providers, as well as other health care workers are very poorly paid. Thus, they either move to higher paying jobs locally or migrate to better-paid jobs abroad. In the past, the most commonly used strategy to retain those valuable health care personnel was compulsory rural service bonds and mandatory rural service for admission into postgraduate training programs. However, the new strategies including well-balanced workforce management policies, incentives, incremental improvement in public health facilities, better residential infrastructure, and local health care provider recruitment have shown promising impacts [23, 24].

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