PQMD Healthcare System Strengthening / Medical Mission Initiative
Medical Mission Literature Review
July 13, 2016
By Myron Aldrink
Executive Summary
Background
On 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 ofcurrent 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).
Methodology
A 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/Documents
The 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 Format
The relevant articles/documents were evaluated and summarized and organized into 5sections.
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
Size
While there is no central source or governing body to collects information, the most often quoted size of US medical missions is 6,000 individualstraveling on medical missionsannually with a total expenditure of $250 million.
Sending/Receiving countries
The vast majority of medical missionsseem to be from the US, Canadafollowed 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 Organizations
Medical 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 organizationsaccounts for 30-50% of all medical missions.
Another important sector of medical missions are medical students. Medical studentteamsare 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 MMprograms
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 MMteams are working to have impact beyond immediate patient care and seek to improve local capacity alongside improving individual health.
Primary Care Medical Missions
Primary Care constitutes the largest number of medical volunteers, followed by surgical medical mission. Primary CareMMs cover a full range ofmedical 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 specificprogram related torural community or urban poor areas or the articles were more promotional in tone.
Surgical Medical Missions
In 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 Missions
There 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 Missions
There 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 internaldocuments on principles, standards, guidelines and best practices. An analysis of the internal documents revealed 8 elements in MMs.
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/MM
While 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/Information
The lack of quality information on medical missions and the lack of a governing bodyhighlights 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 Identification
The MM problems and issuesfound 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 Standard
The 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 andPQMD’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 Focus
The 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 Systems
The 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.
Background
On 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 wasconducted from May 20 to June 15, 2016.
The second step of thePQMD 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.
Purpose
The 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 tostandards and best practices that existed in this area. Also, greater emphasis was given to articleson Primary Care, Surgical and Laboratories (the focus areas selected by PQMD for the HSS/MM Initiative) Theliterature review was conducted from June 20 – July 8, 2016.
Methodology
Given 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
onlinejournals academicand 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 Terms
The 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/Documents
The 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 Format
This report contains 5major 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, Hospitalsetc.).
I MEDICAL MISSION PROFILES
The 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 Profile
In 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 MMis 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 Missions
The literature also indicatesa 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.