IN our last article, we looked at some of the benefits of short-term humanitarian medical missions. Aside from the clear benefits, medical missions also raise several issues and concerns that have become clearer as the frequency of medical missions increase. Our article this week will focus on some of these concerns.

Cost-effectiveness

Medical missions by their nature require significant financial input. Travel costs, hotel stays, visa costs, vaccinations, medical equipment/disposables, and food are all direct costs. The loss of income for the visiting healthcare providers must also be considered. Costs can vary significantly with many factors including the size of the humanitarian mission, the destination country etc, but often these costs may be as high as 10’s to 100’s of thousands of US (United States) dollars. Some authors have argued that if purely economic factors are considered this money could be directly invested in the local health economy as opposed to being used to support the medical mission. In one example, after a short-term medical mission was completed and the costs were tabulated, the money used for the mission would have been sufficient to pay for recruitment, education and retention of a local physician, nurse, allied health personnel along with maintenance of the clinic which hosted the mission for a period of one year. In another example, a medical mission to Ghana was accomplished at the cost of US$30,000. The cost to build a 30-bed wing addition to the hospital which hosted the mission was US$60,000. One question which is frequently asked is, in terms of skill acquisition, would paying for a local physician or nurse to spend time at a centre of excellence in a high-income country be more cost effective and sustainable than a humanitarian mission?

Awareness of local culture, health-care environment and systems

The environment in which health care is delivered is a vital component of the care’s efficacy. Language can clearly be a barrier. While language interpreters can be useful, one can never be sure of what is lost in translation. Even when the health-care providers and patients share a common language, the use of idioms can be an issue. For example, when a Jamaican patient tells a physician that he had an “operation” last night a Jamaican physician and an American physician will construe different meanings from that sentence. Another interesting example is that of many Asian societies where unwelcome news is given to the patient’s family and not directly to the patient himself. There is also a limited concept of patient autonomy compared to the western world. In Thailand, for example, it is uncommon for patients to directly question physician recommendations.

For most personnel that come from high-income countries, the practice of medicine is done on a background of technology. Acquiring lab results, patient historical data and ordering testing simply requires a computer screen and Internet access. For many low- and middle-income countries where humanitarian medical missions take place, it may be necessary to depend heavily on clinical acumen and decision-making without laboratory or radiologic data. One wonders how many developed world physicians can function effectively in such environments. Another issue is that of interaction with the local health-care system. Do they have access to local facilities for complications that arise because of treatment? For patients determined to need specialist care, do they know how to seek it? For the unfortunate patients that are harmed through negligent care do they have a way to seek redress/compensation through the legal system from a physician in another country who may never return?

Sustainability and duration of impact

An important consideration is what happens when the medical mission has left the host country. For some conditions, eg, surgery for hernia repair or cataract removal, once the patient has recovered without complication there is not likely to be an ongoing need to see a surgeon. For other conditions this is not the case. Let us take the example of a woman who is diagnosed with type 2 diabetes by a family physician on a medical mission. She is given her medications for free and has symptomatic improvement when she is reviewed during the last week of the month-long medical mission and is then given enough medication to last a further two months. At that period’s end, the physician who diagnosed and treated her was no longer available. Is the medication that she was given available in Jamaica and if so, is it affordable for her? In the Jamaican context she can be seen at a public clinic at low monetary cost but are there any records summarising her care for the next treating physician? If she lives in an area where no health care is available locally and she cannot afford travel to access health care in the urban centre, is she really any better off than she was before the arrival of the medical mission? From the mission physicians’ point of view, they may have provided care for four weeks, but has this had a long-term impact on the population they visited? An evidence-based assessment devoid of self-absolution would suggest not.

A critical issue that is often overlooked is the effect on the local health-care economy. For missions that are longer in duration, there is the possibility of “crowding out” local practitioners. If the patient can get access to health care at no cost, is there scope for a local practitioner who is unable to work for free? If it is not economically viable to have a practice in the area, the local practitioner may leave the community or significantly reduce his presence. When the medical mission ends, access to care may be less than it was before overseas physicians arrived. This effect can be seen not only in primary care but also in the provision of conditions/procedures which require significant investments of capital, and which depend on patient fees to repay the money invested and hopefully generate a profit. If medical missions are intermittently offering these services at no cost to patients, does it significantly impair the development of a sustainable local health-care system?

In our next article we will explore quality of health-care delivery.

Dr Ernest Madu, MD, FACC and Dr Paul Edwards, MD, FACC are consultant cardiologists for the Heart Institute of the Caribbean (HIC) and HIC Heart Hospital. HIC is the regional centre of excellence for cardiovascular care in the English-speaking Caribbean and has pioneered a transformation in the way cardiovascular care is delivered in the region. HIC Heart Hospital is registered by the Ministry of Health and Wellness and is the only heart hospital in Jamaica. Send correspondence to info@caribbeanheart.com or call 876-906-2107.