Module 3: Partnering with Local Communities
What is the role of the non-profit/NGO in the partnership relationship?(1)
- 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.
- 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.
- 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.
- 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.
What is the role of local doctors in the partnership relationship?
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.”(2)
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.”(3)
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.
To maximize effectiveness, 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.(4) By working with local partners in this way, global health organizations encourage communities to invest in and take ownership of their healthcare systems, which 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.”(5)
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.”(6) 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.
Professional Development and Collaboration
It is important to provide physicians in developing countries with professional development opportunities. The focus of visiting physicians should be to provide skills transfer and professional development while simultaneously providing care to local populations. Doctors working together can be one important facet of continuing medical education. Continuing Medical Education (CME) is required of medical professionals in the United States to maintain their licenses. Every few years, physicians complete a mandatory number of credits through CME approved courses, which are regulated by the Accreditation Council for Continuing Medical Education. CME is important because it helps prevent the deterioration of the quality of care by helping physicians to maintain their position on the cutting edge of knowledge and practices in the field.(7) CME is not available in many developing countries, and educational opportunities with visiting physicians are therefore important and beneficial. By working together, doctors learn complementary skills from each other and improve their individual and group-work skills.(8) Collaboration between doctors is also very important because quality of care and fiscal savings have both been shown to improve when health professionals work well together.(9)
Furthermore, innovation increases as contact with other professionals increases. “Eye surgery is not static and keeps improving. To improve our own surgery, we need to observe other surgeons and, occasionally, copy their techniques,” explains Dr. Walia, ophthamologist and medical director of the Kikuyu eye unit in Kikuyu Kenya.(10) The technology and techniques available to surgeons are continually improving, and it takes collaboration with other surgeons to perfect techniques that can lead to better surgery outcomes for patients.
(1) "Community Health Workers: Recruitment, Payment, Supervision.” Partners in Health Model Online. Model.pih.org. Accessed 8 October 2008.
(2) Edward O’Neil Jr., A Practical Guide to Global Health Service (American Medical Association, 2006), 24.
(4) See, for example, Macfarlane, S., Racelis, M. and Muli-Muslime, F. “Public health in developing countries.” The Lancet. 356.9232 (September 2000): 787-788. Accessed 13 October 2008. <http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T1B-43P3TK1-N&_user=483692&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_version=1&_urlVersion=0&_userid=483692&md5=14378cda622e703dc75afeb6030c5985#bib54>.
(5)“Dr. Clarke Speaks about Volunteers and Unite For Sight’s Importance in Ghana.” Online video clip. Uniteforsight.org. Accessed 8 October 2008. <http://www.uniteforsight.org/intl_volunteer/drclarkevolunteering.php>.
(6) Edward O’Neil Jr., A Practical Guide to Global Health Service (American Medical Association, 2006), 24.
(7) Walia, T. and Yorston, D. “Improving Surgical Outcomes” Community Eye Health Journal Vol. 21, No. 68, pp. 58-59 (2008). Accessed on 3/26/09 <http://www.cehjournal.org/0953-6833/21/jceh_21_68_058.htm>.
(8) Headrick, L. et. al. “Continuing Medical Education: Interprofessional Working and Continuing Medical Education” BMJVol. 316, pp. 771-774 (1998). Accessed on 3/26/09 <http://www.bmj.com/cgi/content/extract/316/7133/771>.
(9) McPherson, K. et. al. “Working and Learning Together: Good Quality Care Depends on it, but How Can We Achieve It? Quality Health Care, Vol. 10, pp. ii46-ii53 (2001)
(10) Walia, T. and Yorston, D. “Improving Surgical Outcomes” Community Eye Health Journal Vol. 21, No. 68, pp. 58-59 (2008). Accessed on 3/26/09 <http://www.cehjournal.org/0953-6833/21/jceh_21_68_058.htm>.