Guidelines For Evaluating Volunteer Abroad Programs
Unite For Sight is a leader in socially responsible, effective volunteering abroad. Our programs apply best practices in global health, volunteerism, and social entrepreneurship. The worst practices that are often employed by some organizations can unfortunately do significant harm and create more substantial barriers to care.
Committed to spreading best practices and eliminating the worst practices that are prevalent in other organizations with volunteer abroad programs, Unite For Sight developed this evaluative framework by which one can evaluate volunteer abroad programs worldwide.
1. Does the organization rely on volunteers?
Best practice: As with any enterprise, extensive human resources provide a great advantage. Each person is able to contribute time as well as their important ideas, talent, and expertise to further advance and enhance programming. Volunteers can offer research ideas and pursue IRB-approved research studies, develop educational material, contribute film and photography skills, and assist with day-to-day operational tasks. Volunteers can be trained to perform basic healthcare tasks such as visual acuity screenings, distribution of glasses and medication, and vital signs. In this way, volunteers improve efficiency by reducing the burden on local healthcare workers, maximizing the time that the local health professionals can spend on examining and diagnosing, and in turn maximizing the number of patients seen. The programs, however, must have the capability to operate with or without volunteers. Programs must be enhanced by the skills and participation of volunteers, and not reliant on the volunteers.
Worst practice: There are many organizations that have programs that rely solely on visiting volunteers to provide healthcare or other services. These programs usually take the form of "voluntourism," "volunteer vacations," and short-term medical missions. Volunteers involved with these programs may perceive that they are making an impact since they do not see or meet any local health professionals providing care or services in the region, therefore leading the visitors to believe that there are no local health care providers. However, they most always do not see health care professionals because they are not linked with the local healthcare infrastructure and the programs they are with do not seek to work with them. If a visiting volunteer perceives that their group is the only option for healthcare in the region, and that patients have no other option but to receive care by the visiting team, then this is an indication that the organization is not providing quality services and is engaging in the worst practices of short-term interventions. By ignoring the local healthcare providers, these programs undermine the local healthcare infrastructure, create new barriers to care, and cause harm. Patients may decide to wait until Western doctors or teams visit instead of seeking care by the local doctors. Oftentimes, it is rich patients who take advantage of free surgical care provided by visiting surgeons despite being able to pay, simply because they incorrectly believe that the Western visitors provide higher quality surgery.
“While [Western medical] teams provide temporary but sporadic access to health care, overall, they do not improve long-term access and they may, in fact, undermine existing services. It is unclear whether the short-term projects are treating only individuals who under current circumstances would have absolutely no access to medical care because of an inability to pay for it, or if they are diverting some otherwise paying or potentially paying patients from local practitioners and facilities. Local practitioners who must earn a living in the community cannot compete with the volunteers who donate their services. Furthermore, they cannot provide the same volume of free care over sustained periods and remain financially viable. Because the patient population… has not been closely analyzed, it is difficult to assess the precise impact on the local health care delivery system. If these groups actually do compete with local providers, the possibility exists that they could be put out of business, further restricting access to health care.”(1)
(1) Montgomery, L.M. “Short-Term Medical Missions: Enhancing or Eroding Health?” Missiology: An International Review. 21.3 (1993): 333-341. Accessed on 20 October 2008. <http://www.mmex.org/Short-termMedicalMissionbyLauraMontgomery.pdf>
2. What type of tasks are assigned to volunteers?
Best practice: Volunteers must assist at their training level and should participate in a support role to local professionals. If they are not a fully licensed and trained medical professional, their involvement with health-related work must not exceed what they would be permitted to do in their home country. They must not provide examinations, perform any tests or procedures on patients, or attempt or provide any diagnosis. For visiting medical professionals, their involvement with patients must be supervised by local health professionals.
Worst practice: Allowing medical providers to practice beyond their abilities is perhaps the worst practice employed by "volunteer abroad" organizations. Oftentimes, medical students and residents see medical missions to developing countries as opportunities to gain unbarred exposure to techniques and procedures they couldn’t perform in their home countries. Other times, visiting physicians feel compelled to treat patients outside their specialty, simply because there is no specialist available. The following accounts clearly illustrate the dangerous pitfalls of involving untrained medical volunteers:
“After finishing my first year of medical school, I participated in a mission trip to Mexico. Before flying to Mexico, I was not given any cultural, medical, or other training, nor could I speak Spanish. Upon arriving, I was assigned to a clinic where there were hundreds of patients seen by only one physician. I remember vividly seeing a frail 11-year-old boy with polyuria, polydipsia, and nocturia. My lack of medical training limited my differential. With only a scattered history and no other tests, I told him to limit caffeine intake and see if that helps. Thinking back, he could have had a urinary tract infection, any number of renal abnormalities, or worse, I sent him out without ruling out diabetic ketoacidosis. And while I was seeing patients by myself, other first year medical students were performing surgeries in the other clinics and later bragging about it."(2)
"A young medical student, referring to himself as "Dr. Jones" arrived in a village in a Central American country during an unsupervised elective course. He greeted the villagers with bags of candies, quickly winning over the interest and affections of the children. He was able to move easily among them, taking photographs and earning their trust. He was summoned one day to the bedside of an extremely ill baby and was asked by some of the villagers to help her get better. After an exam during which he used his stethoscope and otoscope, both of which were unfamiliar to the family, Dr. Jones recognized that the child was extremely dehydrated with a high fever. Without access to the kinds of diagnostic tools--laboratory tests and radiological examinations--on which he usually relied for information--he was unable to determine the cause of the chlid's illness. He told the family to give her fluids and acetominophen to keep the fever down. He was unfamiliar with the family's usual dietary habits and never inquired if the child was being breasfed or if the family had a source of potable water that would provide a suitable alternative. Unfortunately, the child died within a few days of Dr. Jones' bedside visit. The families of the village became convinced that his ministrations were the cause of the baby's death. His instruments and the medications that he gave her aroused suspicions that he may have introduced the 'evil eye' or mal de ojo, a potential source of illness, or even death. Because he had taken many pictures of the children in the village, others became concerned that he had used the images of the children to inflict future suffering. After the death of the child that Dr. Jones saw, subsequent visits by white American medical personnel were prohibited by the villagers, even though a need developed for immunizations when a measles epidemic swept the country."(3)
(2) Shah, S. and Wu, T. “The medical student global health experience: professionalism and ethical implications.” Journal of Medical Ethics. 34 (2008): 375-378. Accessed 20 October 2008. <http://jme.bmj.com/cgi/content/full/34/5/375>
(3) Levi, A. "The Ethics of Nursing Student International Clinical Experiences."Journal of Obstetric, Gynecologic, & Neonatal Nursing. 38 (January 2009): 94-99.
3. How are volunteers trained?
Best practice: Proper training is essential for volunteers. Well-prepared volunteers must understand local patient barriers to care, how the organization functions and operates, policies and procedures, and the importance of ethics, professionalism, and cultural competency. Those traveling to developing countries must first be educated about local culture and familiarize themselves with their target communities. The second component to volunteer training is pragmatic. Volunteers must be competent to carry out their duties, which may include education, basic medical tasks, etc. All volunteers participating in any health or development setting must also have training in international development and best practices in global health. All participants should understand global health practices and why and how the organization's programs function.
Worst practice: Untrained or poorly trained volunteers can do significant harm by propagating false information, or by interfering with proper medical care. For example, volunteers who are not properly trained about HIV/AIDS cannot accurately educate local community members about prevention and treatment. During teaching sessions or one-on-one counseling, any misinformation or incomplete information can have serious ramifications for a local community's understanding about health and disease.
Volunteers who are not both practically and psychologically competent to work abroad can end up being a burden to the local community. Without training, volunteers will be psychologically and culturally unprepared to work amidst poverty in a developing country. Volunteers who are overwhelmed by culture shock or sadness can burden the rest of the team. Additionally, volunteers unfamiliar with cultural norms can unintentionally offend locals, thereby becoming a liability and negatively impacting local communities and partners.
Unprofessional behavior is a serious problem amongst volunteers participating internationally in any organization, and this type of attitude has extreme and widespread consequences. A common symptom of culture shock is criticizing elements of the local culture, which is particularly inappropriate behavior for visiting volunteers. An even more subtle cause of unprofessional behavior is ethnocentrism – the unconscious presumption that there is one normal, single way of doing things, and that deviations from this universal order are wrong. Ethnocentrism is a dangerous pitfall for volunteers stationed in health clinics abroad, as approaches to health care vary widely; the best approach to patient care heavily depends on context, customs, and patient beliefs. Ethnocentrism can lead to a lack of respect for local partners and patients, which can undermine local healthcare providers.
Some cases of unprofessionalism are extreme (e.g. discovering the program isn’t what you expected, and leaving early), but most are unintentional, subtle, and seemingly benign (e.g. throwing on your scuffed sneakers and wrinkled button-down shirt thinking nobody will notice). Examples of unprofessional behavior that are particularly pertinent to international volunteering include showing up late or not at all; leaving early; inappropriate dress; violation of cultural norms; being overly demanding; laziness; negligence; unreliability; a condescending, disrespectful, or arrogant attitude; and noncompliance with direction. This type of unprofessional behavior can distract local organizations, NGOs, and healthcare providers from their missions. Instead of focusing on their important community work, they need to utilize their valuable time to monitor and chaperone undisciplined or difficult volunteers. With proper preparation, training, and focus on the consequences of unprofessionalism, all volunteers are capable of ethical, professional conduct in the international setting.
4. How does the organization represent the volunteer opportunities?
Best practice: When volunteering internationally, all participants must be led and managed by local professionals. If working in the health field, volunteers must be directly supervised and constantly working under the direction of local healthcare professionals.
Worst practice: Volunteering abroad programs are frequently considered or represented as a "vacation," "adventure," "escape," or "travel opportunity." Organizations with this type of representation indicate that they are marketing programs to vacationers and do not have a commitment to supporting local professionals. Just as employment in the U.S. is not considered a vacation, volunteering (employment without pay) in a developing country should not be considered a vacation or represented as an adventure. Volunteering requires the same level of devotion and professionalism as a job. Those looking for a vacation are unprepared for the rigors of volunteering abroad and are especially prone to unprofessional behavior that can undermine local communities. Representing volunteer work in developing countries as an "adventure" indicates a disrespect for the local community and for the developing world as a whole.
The photographs on an organization's website can also give an important indication about their level of respect for the local community. The organization's website photos should indicate that they are humble, considerate, and respectful. The website should not make stereotypes, generalizations, or try to exploit public sympathy. Those in the photos should never be shown as objects of pity awaiting a visitor to help.
5. Does the organization require an application?
Best practice: Just as employers and universities require applications, volunteer organizations must ensure that only quality participants will become involved with their organization. The application process should be rigorous so that the organization can learn about the prospective volunteer's motivations and intentions. Requiring references and letters of recommendation demonstrate that an organization is serious about the quality of its participants and the importance of its work and programs.
Worst practice: Oftentimes organizations enable prospective participants to register, "apply", or become a member without an actual application process. This does not ensure that the participant will fit well with the mission or intentions of the organization, and it demonstrates that the organization lacks seriousness about implementing quality programs in the field. When providing human resources to local communities, local NGOs, and local healthcare providers, it is extremely important that the volunteers are vetted and that only high quality applicants are accepted to participate. Unqualified participants are not able to meaningfully contribute, oftentimes require close monitoring of their conduct and behavior, and therefore distract local organizations from their missions and daily operations.
6. How does the organization utilize funding?
Best practice: It is important for organizations to use their funding to directly benefit the local community.The organization should undergo regular financial audits, and the organization should make it clear how and why the organizational funding is used for specified purposes. The funding must be used in a cost-effective and fiscally responsible way.
Worst practice: While some "volunteer organizations" are nonprofit, others are for-profit. This distinction does not, however, explain how the funding is used. It is important to review organizational financial reports to determine if and how their funds benefit the local community. Many organizations utilize most or all of their funds on headquarters staff to operate as a tour company or a travel agency. Others state that funding is provided to local communities, but there is no indication about how much is used, how it is used, or how the organization determines how and why to allocate funding to a particular project or community.