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Module 3: Partnering with Local Communities

Importance of working with local doctors and partners(1)

Q: “Which single intervention would do the most to improve the health of those living on less than $1 per day?”
A: “Hire community health workers to serve them.” – Dr. Paul Farmer(2)

Research on the efficacy of global health organizations leaves little doubt as to the importance of working with local partners and doctors:

“The balance of evidence from published literature and case study accounts is clear…The greater the level of local community involvement in setting agendas for action and in the practice of health promotion, the larger the impact.”(3)

“Health programs should involve community members at all levels of assessment, design, implementation, and evaluation.”(4)

“To increase quality of interventions, communities must become partners of the health system.”(5)

The involvement of local community leaders, volunteers, health workers, and clinics is essential in producing sustainable improvements in healthcare. The following six aims of global healthcare programs outline the many roles of local workers, and illustrate the critical value of partnerships.

Confidence: Though patients might be skeptical about visiting doctors, local leaders are seen as trustworthy, and they inspire confidence in the mission of the global health organization. Alternatively, if organizations fail to work with local medical personnel, they may undermine the community’s confidence in the local health system, which will further diminish public health.

Continuity: Without the dedication of local on-the-ground partners, healthcare improvements implemented by global health organizations can only be temporary, at best. Follow-up, ongoing, and preventive care all depend on the presence of local medical providers. Local partners are permanently in-country, and are in the best position to link patients to year-round medical care.

Comprehensiveness: Local leaders and health professionals are best equipped to assess community needs. While visiting physicians can observe patients’ symptoms and determine the baseline status of the community’s health, local doctors are familiar with the underlying roots of these health problems, as well as with patterns of disease and treatment. Similarly, on-the-ground collaborators are familiar with the needs of particular communities, and can act as case-finders. Without local insight, it would be nearly impossible to deliver the appropriate healthcare to the entire community.

Coordination: Global health organizations often face complex logistical challenges when entering communities that have limited infrastructure. Local staff members can facilitate logistical details from transportation and lodging to assessing medical needs to publicizing programs in the community.

Cultural Sensitivity:

“From the local world of the community clinic or oncology unit to the transnational workings of human rights agencies, attentiveness to the concept of culture can illuminate how patients, family members, and health care providers interpret illness, healing, and moral obligations.”(6)

It is important to remember that the local health workers coordinating these initiatives are also part of the target community. They understand cultural norms and can generally relate better to patients than the visiting doctors can, thereby improving healthcare delivery. As the link between the community and the healthcare system, local partners are critical in ensuring effective communication and cultural sensitivity.

Capacity:(7) Healthcare delivery systems must be continually maintained and improved. Without community collaborators, health improvements implemented by global health organizations are only transient. Healthcare workers are essential to healthcare delivery, and are therefore a part of the greater infrastructure. In order to achieve the ultimate goal of a permanent high-quality medical system, global health organizations must rely on capable local medical providers, health workers, and other community leaders. Only after building local capacity can a healthcare system become self-sustaining.

What is the role of the non-profit/NGO in the partnership relationship?(8)

• Recruitment 
  • A global health organization must not begin programs before finding and mobilizing local collaborators, and in particular, local medical clinics. Once a commitment to the common goal of healthcare improvement is established, NGOs and their collaborators can begin recruiting community health workers and volunteers. It is essential that global health organizations recruit and train trustworthy, competent, and caring local community members to serve as health workers. In resource-poor settings, there are often many available unemployed workers to fill these roles, and local leaders and community members can be surveyed to ensure that those recruited have the appropriate motivations and character traits.
• Training
  • Global health organizations can engage in the training of local health workers and volunteers. The tasks of these partners include education, case finding, and health assessment, all of which require new skills and knowledge. When necessary, educational opportunities for physicians and nurses should be provided as well.
• Funding
  • A primary role of nonprofits and NGOs is to fund global health endeavors. While some local community members will volunteer as coordinators, health workers and other community collaborators should be compensated for their efforts. They are trained to carry out essential healthcare, educational, and logistical tasks, often under difficult circumstances. It is important for payment to be in line with the salaries of other local workers to avoid building resentment and disrupting the local economy. If a medical facility is lacking critical equipment, NGOs and nonprofits should strive to provide it. Funding should also help subsidize the cost of medical care, as patients targeted by global health organizations generally cannot afford to pay (the full rate) out of pocket.
• Monitoring
  • To ensure effectiveness and progress, all aspects of global health endeavors must be subject to evaluation and feedback. Volunteers and health workers should have supervisors, such as a community nurse or doctor, to whom they can report, and who can monitor their activity. Communication between global health organizations and their local collaborators must be open and frequent. A lack of responsiveness, honesty, or flexibility indicates a failing partnership.

Medical care should not be provided unless local doctors are integral to the program

Collaborating with local doctors is essential for efficient and effective healthcare delivery for a variety of reasons. Local doctors are in the best position to understand the needs and situation of the local community. These local providers are familiar with the etiologies and distributions of diseases in their communities. They are also keenly aware of regional aspects of public health such as hospital patterns, who has access to care, and how best to distribute resources. Additionally, many Western physicians are unfamiliar with tropical diseases and rely on the expertise of local doctors to make correct diagnoses and prescribe effective treatments. Dr. Edward O’Neil, Jr., president and founder of Omni Med, has experienced first-hand the vital role that local doctors play in global health programs:

“…most visitors – including ours – to poor countries are amazed at just how much local providers are able to do with so little. Many visiting clinicians find themselves learning much from their hosts. Indeed, few US or European clinicians have seen many of the tropical illnesses that local providers recognize so readily. Even the best-trained Western physicians initially flounder.”(9)

As a volunteer with Unite for Sight, American ophthalmologist Dr. Aron Rose discovered the quality and importance of local doctors. He explains this by detailing his own experience working as a foreign doctor in partnership with local ophthalmologists in Ghana:

“As a microsurgeon, it’s extraordinarily challenging to be out of your element. In this society, we’re used to using absolutely top-notch equipment… What I have found is that working overseas challenges a surgeon tremendously… In many ways, I think that surgeons operating in underdeveloped or developing countries have to be even better doctors because 1) they’re dealing with an array of pathology that is much greater than we generally see in the developed world, and 2) they’re being forced to use what they have… I end up learning so much more when I travel than anything I could possibly teach.”(10)

Integrating local doctors into global health programs is similarly essential for sustainability. A global health program that does not seek to support local healthcare providers can (at best) only yield temporary improvements. Long-term improvements in community health require ongoing follow-up care and a broadening of the reach of local doctors’ practices so that more patients have access to year-round care.

Failure to involve local doctors in global health programs can yield various deleterious effects. For instance, medical treatment without follow-up care can be more harmful than helpful, and foreign medical providers unfamiliar with cultural norms often struggle to communicate with patients. Further, excluding local doctors subverts community trust in local healthcare programs. Dr. Edward O’Neil, Jr. notes that in spite of their expertise, there exists a widespread belief among locals and foreigners alike that local doctors are “inferior clinicians.”(11) This belief is reinforced when Western physicians refuse to collaborate with their local counterparts. Undermining the legitimacy of local doctors can only harm community health.

Who ultimately has authority?

Local doctors should be in charge of local programs. When it comes to assessing who needs what resources, community leaders and medical providers know best. Global health organizations aim to provide support and direction, but should not hold the decision-making power. Top-down approaches to global health development that place power in the hands of government or large organizations have proven to be inefficient, ineffective, and susceptible to corruption. Thus, NGOs and non-profits are encouraged to implement a bottom-up, grassroots approach.(12) By working with local partners in this way, global health organizations encourage communities to invest in and take ownership of their healthcare systems. This ultimately leads to sustainable improvements. Dr. James Clarke, one of Unite For Sight’s partner ophthalmologists in Ghana, explains how working through communities instead of through governments has facilitated healthcare expansion:

“We really need to encourage a lot of NGOs who are interested in eye care to follow Unite For Sight’s example, namely to work from the bottom up. You know, when NGOs come into a country and they approach the government, the authorities, they don’t come and do eye care. When it starts, there are a lot of costs – the overhead, the running of the program – so very little actually goes to those who should benefit from the program. But in the case of Unite For Sight, they came, they got in touch with us – a very small clinic – and when we started outreaches to communities, people started benefitting… Initially when it started we would write letters to districts, to churches, to communities asking if we could do outreach. When we started and people started seeing the results, they were calling us and writing to us and inviting us. We don’t have to make any contacts again. There are so many people that are waiting for us.”(13) – Dr. James Clarke, Crystal Eye Clinic, Unite For Sight Partner in Ghana

Go to Module 4: Build Effective, Sustainable Programs With Measurable Results>>

Footnotes

Global Health Course

• Table of Contents
• Module 1
• Module 2
• Module 3
• Module 4
• Module 5
• Module 6
• Module 7
• Module 8
• Module 9
• Module 10
• Module 11