A Role for Short-term Volunteers in Global Health

Abstract: Properly trained volunteers with interests and motivations that match the needs of settings with limited resources help meet the global shortage of well-trained healthcare workers. Health Volunteers Overseas (HVO) paves the way for successful volunteering experiences that help improve healthcare outcomes and enrich volunteers’ lives.
Address correspondence to: Nancy Kelly, MHS Health Volunteers Overseas 1900 L Street, NW #310 Washington, DC 20036 Phone: 202-296-0928 E-mail: n.kelly@hvousa.org

     In 2006, the theme of the World Health Organization’s (WHO) annual report was Working Together for Health. As Lee Jong-wook, the late Director-General of WHO, stated in his opening message about the chronic shortage of well-trained healthcare workers:       “The shortage is global, but most acutely felt in the countries that need them most. For a variety of reasons, such as migration, illness or death of health workers, countries are unable to educate and sustain the health workforce that would improve people’s chances of survival and their well being.”      The last decade has been characterized by a dramatic increase in interest and resources in global health—the Gates Foundation and the funding of PEPFAR are two excellent examples.¹ To a large extent, this heightened awareness has been driven by the grim realities of the HIV-AIDS pandemic which has decimated families, villages, and countries all around the world. The advent of SARS and the flu pandemic have also contributed to growing awareness that the Earth is a small planet where diseases can be transmitted quickly with potentially devastating outcomes.      Increasingly, healthcare policy experts have come to realize that while there are financial resources and technologies available to address many health challenges, the health systems found in countries around the world are weak and are not able to deliver the services that are needed. A WHO Report states that a shortage of human resources has replaced financial issues as the most significant obstacle to implementing national treatment plans.²      Health systems in developing countries are chronically under-funded and under-staffed. There are numerous barriers to access with poverty being perhaps the most significant recurring barrier across all countries. In some countries the per capita expenditure on health may be less than $10 annually. Health professionals and facilities tend to be concentrated in major cities with few, if any, services available to the rural population.

Investment in Education—A Possible Role for Short-term Volunteers

     Investment in the education and training of local healthcare professionals is vital to ensure that healthcare delivery systems in developing nations are able to handle the diverse needs of local communities.³ Indeed, a healthy and productive population is a prerequisite for economic development and opportunities for advancement both at the societal and the individual level.      By definition, educational programs take a long view of human development. The introduction and assimilation of new information, techniques, and clinical concepts takes time. New approaches and ways of thinking about a disease pattern or long established clinical practice often require multiple pedagogical approaches including modifications of existing curricula, teacher training, and the provision of updated educational materials.      Given the long-term nature of educational programs, can short-term volunteers play an effective role in such programs? Some say that short-term volunteers are “more work than they are worth,” essentially a distraction from the “real” work of improving the lives of people in countries that lack access to even the most basic healthcare necessities. The short-term volunteer model may be ineffective in situations where the volunteer’s role has not been clearly defined and in instances in which the program design has not been adapted to effectively utilize the talents of individual volunteers.      When properly prepared and matched with programs where their unique contributions are maximized, however, short-term volunteers can and do make a significant contribution to the education and training of healthcare providers in developing countries. This article will address the various components of one such model that was utilized by Health Volunteers Overseas for developing successful educational programs staffed by short-term volunteers.

Health Volunteers Overseas (HVO)

     HVO is a “network of healthcare professionals, organizations, corporations, and donors united in a common commitment to improving global health through education.” HVO sponsor membership comprises more than 500,000 healthcare professionals.      HVO has partnerships with 60 collaborating institutions, including hospitals, Ministries of Health, and other agencies in 24 countries. HVO’s Wound and Lymphedema projects are a partnership with the AAWC Global Alliance. They proceed according to a standardized model (Figure 1) developed and honed with HVO volunteer feedback since 1986. Members of the AAWC and CAWC are eligible to volunteer and should visit the HVO website for more information (www.hvousa.org).      Over the past 23 years, HVO has developed a reputation for designing strong, effective clinical education programs in developing countries that successfully utilize short-term volunteers according to a standardized process outlined in Figure 1. The purpose of these programs is to train and support local healthcare professionals, giving them the knowledge and skills that will enable them to provide better care within their community. In addition, HVO programs also foster the development of professional networks, providing opportunities for healthcare professionals around the world to interact on national, regional, and international levels.⁴

The HVO Model

     The HVO Model for optimizing the overseas volunteer process is based on five key elements:      1. Appropriate, invited intervention, and support      2. Sustainability      3. Volunteer screening      4. Volunteer orientation and preparation      5. Recognition of the realities (limits) of the model.      Appropriate, invited intervention, and support. The central tenet of appropriate involvement is to provide assistance only when invited and welcome. Intervention and support should be guided by the principle of enabling local healthcare workers to operate self-sufficient programs. Education is the most effective approach to achieving a sustainable solution; a system that provides appropriate care and a continuous supply of competent medical personnel. During the site assessment, it is critical to identify the educational needs and priorities and to determine if it is realistic to implement a program to address these needs.      Language is another important consideration. It is very difficult to sustain a teaching program in another language, as provisions for translators are often necessary. Lastly, a certain level of political and social stability must be in place for an educational program to be effective. War, upheaval, and ongoing local strife will negatively impact attendance, and not surprisingly, will result in poor results. Political instability will also negatively impact volunteer recruitment.      Sustainability. In order to effectively utilize the time and talents of short-term volunteers, the site must be committed to their presence. This commitment must exist at all levels from the top administrator to the trainees. Organized time for lectures, clinical education sessions, and other teaching opportunities should be planned in advance.      The sustainability of the training is another factor that is often overlooked. Some organizations rely on equipment and advanced training techniques, and while high-tech solutions may seem attractive, several barriers exist. Often the lack of affordable supplies or replacement parts and the lack of trained biomedical engineers to inspect and repair equipment result in expensive equipment quickly becoming inoperable. In wound and lymphedema care, the lack of resources impacts the availability of consumable products like dressings, bandages, and footwear; this may impact what can be taught and sustained. In many cases, basic wound care principles are the most crucial training that patients can use at the home-based level. For wound and edema care those home-based principles are:      1) Manage the underlying condition      2) Infection control      3) Moist wound healing      4) Protect against chemical and mechanical trauma      5) Control edema      6) Promote tissue tolerance      7) Patient education and communication.      Another aspect of a sustainable program is to teach process activities. Standardize basic documentation, wound assessment, risk assessment and link those activities to routine preventive interventions: how to collect data to determine the scope of the problem, how to establish a baseline, and evaluate the outcomes of interventions. Such assistance can promote interdisciplinary collaboration, which is often a new concept.      The other important component of a sustainable program is an individual on site who will support the volunteers when they are in-country. This individual may be one of the trainees but this is not always the case. This in-country individual plays the vital role of liaison between the volunteer, the personnel on site, and the home office. The local coordinator’s ability to handle problems, smooth ruffled feathers, and serve as a cultural and linguistic translator is essential to the continuity of the program given the frequent rotation of volunteers through the site. Most volunteers are not “high maintenance,” but even the ideal volunteer is bound to ask numerous questions and will need direction on occasion.      Volunteer screening. Developing a mechanism for recruiting and screening volunteers is essential. Many people are interested in volunteering, but enthusiasm and good intentions are not enough. Potential volunteers should understand and be committed to the mission of the organization with which they are seeking an assignment. A clear statement of the organization’s mission and its expectations helps to frame this issue for potential volunteers.      At HVO, volunteer screening is handled by program directors who are also volunteers (Figure 1). Programs are managed by volunteers, and in the case of the wound and lymphedema programs, by specialists who have been to the site and are intimately involved in the implementation of the program. These program directors devote many hours every week to a variety of tasks including talking with potential volunteers, interacting with the site, debriefing returned volunteers, and checking references for volunteers about to be added to the schedule.      During the screening process, it is also important to determine the motivations of the applicant. Many are interested in “giving something back” to the world. They must recognize, however, that change occurs slowly and they may not see immediate results from their visit. Occasionally, someone will indicate that they are in the middle of an unpleasant divorce or some other personal situation that they would like to extricate themselves from for a period of time. Volunteering overseas under these circumstances is not recommended.      Other motives occasionally surface that need to be considered. For example, a potential volunteer may want to conduct a research trial at the site. This needs to be handled carefully and integrated gracefully and practically into existing programs with the full understanding and cooperation of the host institution in order to ensure that there are no ethical breaches. Properly screening of the volunteer applicant takes time and involves numerous conversations with both the applicant and references. The result is a volunteer experience at once congruent with healthcare needs at the site and with the volunteer’s personal goals and skills.      At HVO, potential volunteers are asked to provide three references on their volunteer profile form. Forms that are lacking this information are not processed until this section is completed. All reference checking is handled by the program directors who seek feedback not only on professional matters, but also on the personal characteristics essential to a successful and effective volunteer: patience, flexibility, a sense of humor, and strong communication skills.      Volunteer orientation. By the time the volunteer has actually cemented a specific assignment and begins to make plans for the trip, he or she should have a fairly well-developed understanding of the organization, its mission, and their right standing agenda as a volunteer once he or she arrives onsite. Organizations that place volunteers overseas have a responsibility to clearly state their principles and philosophy. There should be no hidden agendas or surprises. Volunteers should know and understand what they are getting involved in and what is expected of them.      In actuality, many potential volunteers are put off when they hear the words “teaching and training.” Those in private practice often wonder if their experiences and clinical knowledge are relevant and useful in developing countries. They worry about being in places where resources are scarce and where pathologies are significantly different from what they are accustomed to at home. Many opt out of the program being considered at this point, because they are overcome by doubts and concerns about what they have to offer. Quality orientation tools based on returned volunteer reports and experiences can help allay or address these concerns so that prospective volunteers embark on their experience with realistic goals and understanding of how their activities may or may not impact clinical outcomes in their volunteering environment. They may also learn simple, clear objective cues to watch for that will help them assess the difference(s) made by their training or other volunteer activities.      HVO has developed an array of materials designed to educate and orient potential and assigned volunteers. A critical document in this process is HVO’s Guide to Volunteering Overseas. At 35 pages, the guide is relatively short, but covers a variety of topics including the fundamentals of teaching in a different culture, the realities and constraints of healthcare delivery in developing countries, and personal health and safety.      Trip reports from returned volunteers are another valuable source of information and education, as are opportunities to interact with program directors and returned volunteers. Reports provide information about the needs of the community, the program’s local mission, organization, and history in the region, and anecdotes. Publishing reports in specialty journals and department reports can help generate awareness of the status and ongoing needs of a program. The Internet and its astounding array of resources also provide useful background information on local cultures including belief systems related to disease and illness.

Recognizing the Realities (and Limits) of the Model

     The average length of an assignment with HVO is 4 weeks. This is both a strength and a weakness and must be acknowledged as such. A 4-week assignment (some assignments are shorter) is short enough to enable a physician in private practice or in an academic setting to participate. Many other organizations require longer time commitments, often 12 months or longer. It is easy to understand this requirement as short-term volunteers do require a significant amount of support and guidance. Despite this weakness, with proper training and placement, even short-term volunteers become important links in the chain of events leading to improved healthcare outcomes.      A significant drawback related to the short-term nature of these assignments is the lack of continuity of volunteer coverage and lack of coordination between volunteers. Last minute cancellations are a recurring problem and can have a negative impact on a site that has invested time and energy in making arrangements—scheduling teaching sessions, making housing arrangements, setting up appointments, etc. Unfortunately there is little that can be done to reduce the incidence of these cancellations, as most are a result of life altering events such as an illness in the family. The lack of coordination between volunteers, however, is a shortcoming that can be addressed. In this new era of instant communication, it is much easier to assure that volunteers are in touch with personnel at the site, recently returned volunteers, and the program director.      One complaint from sites is that volunteers teach the material with which they are familiar. While this is perfectly understandable, the information and instruction is not necessarily useful in the context of the program, especially if the same topic is addressed repeatedly. This challenge can be addressed in the design of the program and in the preparation of each volunteer. Once again, the role of the program director is critical for briefing volunteers prior to departure. The volunteer should have an awareness of topics that have been discussed by previous volunteers. On occasion, a returned volunteer may indicate some concern about how well the trainees grasped a new concept or how it is being incorporated into daily practice. This concern can be shared with the new volunteer so that he or she can follow up on this concern and reinforce the teaching.

Thorough Volunteer Preparation = Success

     HVO has demonstrated the short-term volunteer model to be successful. The organization mission and philosophy are clearly conveyed to prospective volunteers. HVO works with the program sites to determine their unique needs and conditions and tailors the programs appropriately. The sites invest in the program by designating a program liaison, providing support for the volunteers (eg, housing, in-country transport), and participating in the program design. Volunteers are thoroughly screened for skills and expectations, and briefed through contact with previous volunteers at the site, with the site itself, and through a vast array of site-specific online information and reports.      Properly prepared volunteers and well-designed programs can lead to a successful experience and can begin to address one of the world’s scarcest resources—healthcare professionals.