Principles to guide a volunteer humanitarian faith-based short-term medical mission in Nepal: A case study

Global health inequities, natural disasters, and mass migration of refugees have led to an increase in volunteer humanitarian responses worldwide. While well intentioned for doing good, there is an increasing awareness of the importance for improved preparation for international volunteers involved in short-term medical missions (STMMs). This case study describes the retrospective application of Lasker’s (2016) Principles for Maximizing the Benefits for Volunteer Health Trips to international volunteers from two faith-based non-governmental organizations (NGOs) in Canada and the United States partnering with a faith-based NGO in Nepal. These principles are intended to maximize the benefits and diminish challenges that may develop between the international volunteers and the host country staff. Lessons from this case study highlight the importance of applying such principles to foster responsible STMMs. In conclusion, there is an increasing call by host country staff for collaborative and standardized guidelines or frameworks for STMMs and other global health activities.


Introduction
Over the past several years, there have been numerous natural disasters and migration of refugees that have resulted in catastrophic disruptions in the health and wellbeing of those afflicted. 1,2,3,4 This has been associated with a mobilization of volunteer activities and humanitarian assistance worldwide. 2,5 While these international volunteer activities are well intentioned, they can often be misaligned with the host countries' staff desires and preferences, particularly by focusing on downstream, episodic care. 6 This has the potential for unintended and harmful consequences for the host country and may exacerbate global health inequities. 7,8 On April 25, 2015, Nepal suffered a 7.9 magnitude earthquake that killed 8700, injured 22,000, and displaced 2.8 million people. Then, on May 12, 2015, Nepal experienced a second devastating 7.3 magnitude earthquake. 9 In 2015, Nepal had been ranked 158/188 in health performance in the world. 10  exacerbated Nepal's already high burden of disease and magnified health inequity in one of Asia's poorest countries. 10,11 In response to these devastating earthquakes, there was an immediate outpouring from various international organizations to provide aid, disaster relief, and funds. 12 Among others, three faith-based NGOs responded to the call: (1) a Canadian church NGO focusing on refugee relief, education, and human trafficking, (2) an American NGO focusing on disaster relief, and (3) a Nepalese NGO primarily focusing on human trafficking, particularly of vulnerable children and youth. The invitation to the North American NGOs from the Nepalese NGO requested assistance with infrastructure projects and medical clinics after the earthquakes and has resulted in an ongoing partnership. The Canadian and American NGOs accepted the invitation to work alongside the Nepalese NGO to support their goals and objectives. This included short term medical missions (STMMs) to provide annual medical care and to help rebuild structures destroyed during the earthquakes. STMMs have been described as a "grass-roots form of aid, transferring medical services rather than funds or equipment." 13( In addition, others have described short-term global health trips as lasting from one day to two years, but most commonly two weeks. 14,15

Case Study
This case study describes the retrospective application of Lasker's (2016) Principles for Maximizing the Benefits for Volunteer Health Trips to international volunteers from two faith-based non-governmental organizations (NGOs) in Canada and the United States, partnering with a faith-based NGO in Nepal. Initially, this partnership between these three faith-based NGOs was built as the result of the humanitarian crisis in Nepal. The American based NGO provided medical teams to support host country staff in Kathmandu and in remote villages located in the Himalayan foothills. Over the past three years, the Canadian and American NGO volunteers have worked in partnership with the Nepalese NGO to continue providing primary medical and dental care in these areas during their annual STMMs.

Purpose
The purpose is to describe the retrospective application of principles for international volunteers to a specific case study demonstrating how these principles maximize the benefits and diminish challenges that may develop between international volunteers and host country staff in a STMM. Recently, there has been increased awareness of the importance of improving the preparation for international volunteers involved in STMMs when serving under-resourced communities. 14 In this case study, no specific principles guided the volunteer STMM among the Canadian, American, and Nepalese faith-based NGOs. To date, the preparation for the international volunteers has consisted of pre-departure team meetings. Lasker emphasizes the importance of having, "a set of standards to guide global health efforts toward the best possible outcomes." 5 Lasker acknowledges that other guidelines for practice in global health exist, but their focus may vary due to expectations from volunteers. As a result, Lasker developed nine principles, based upon her and others' research, that, "would be most likely to have an impact in creating effective health-related volunteer programs." 5

Principles for Maximizing the Benefits for Volunteer Health Trips 5
Lasker's principles are described and retrospectively applied and evaluated to the case study. The principles are as follows: (1) Foster mutuality between sponsor organizations and hostcountry partners at every stage; involvement; (4) Evaluate process and outcomes and incorporate the results into improvements; (5) Focus on prevention; (6) Integrate diverse types of health services; (7) Build local capacity; (8) Strengthen volunteer preparation, and (9) Have volunteers stay longer. 5 The application of Lasker's principles may be a useful guide for describing and better understanding the strengths and limitations of the partnership between the three faith-based NGOs described in the case study. The first principle, "foster mutuality between sponsor organizations and host-country partners at every stage," 5 describes many types of international collaborations whereby mutuality is valuing of the knowledge of both the visiting and host perspectives. In this faith-based partnership, the host country staff's knowledge of the community's needs was integral to ensuring that optimal care was provided. From there, the Nepalese NGO engaged in conversations with the individual community stakeholders as to where they would like their clinics to be located. This ensured that the Canadian and American NGOs provided aid and assistance in alignment with the preferences and needs of the Nepalese host communities. In the beginning, the volunteers from North America operated the medical clinics along with Nepali translators, but as this collaboration progressed into the second year, a Nepali dentist joined the healthcare team. The addition of a host dentist and the continued relationship with the Nepali translators created an opportunity for mutual learning, which enabled the visiting volunteers to better understand and appreciate the needs of the Nepalese population.
The second principle, "maintain continuity of programming," refers to the consistency, predictability, and sustainability of a STMM. 5 Continuity of programming holds the potential for better health outcomes as it leads to strengthening the collaboration between the international volunteers and host communities. Lasker further advises, "without a plan and the possibility for continuity, billions of dollars of international development aid and global health assistance can be wasted." 5 As these international volunteers have been serving the same community for a number of STMMs, over time trust between the partners has been steadily growing. As a result, there is ongoing clarity of what the international volunteers are continuing to provide relative to medical and dental care, and the host staff are clearer of their roles and what they can offer to maintain the sustainability of care once the international volunteers have left. The ongoing planning between the international volunteers and the host staff community has allowed other programs to be instituted based upon the changing needs of the host community, for example, the offering by the Nepalese NGO of human trafficking prevention seminars.
Next, Lasker emphasizes in the third principle the need to "conduct substantive needs assessment, with host-community involvement." 5 This principle involves a structured approach towards assessing the perceived and actual needs of the host community. This serves to provide the most benefit: the ultimate goal of the majority of STMMs. 5,16 This principle is also acknowledged as important in the global health literature when addressing the needs of visiting student trainees and hosts. 17 Throughout this partnership, the visiting NGOs have actively sought and valued the involvement of the host staff and community. For example, the volunteers on the STMM have relied upon the host organization and community to conduct needs assessments to determine the optimal location for the medical and dental clinics.
Lasker's fourth principle focuses on the importance of evaluating, "process and outcomes and incorporate[ing] the results into improvements." 5 There are several reports of successful STMMs, yet when Lasker asked, "How do you know if your program is benefiting the host community?" there were few objective responses by the various programs. 5 It appeared that the success of a STMM is often based upon the assumptions and feelings of the visiting volunteers. 5 The current STMM did not use any formal evaluation processes, however, they did ask the host organization to follow up on specific patient concerns. It could be argued that without sufficient medical follow-up, the efficacy of the health care provided may often remain unknown to the volunteers and the host community, which is a common issue amongst STMMs. 5,7,17 In this particular case study, the Canadian NGO evaluated the volunteer experiences by having them complete a survey. This is an example that illustrates the high priority placed upon volunteer experiences rather than the host community benefits. As a result, this reflects the need for a paradigm shift away from only assessing the volunteer experiences, and toward the inclusion of the host community experiences. 16 Another aspect of the paradigm shift needed leads to Lasker's fifth principle of a "focus on prevention." 5 Lasker describes this as a move away from a traditional medical mission model and towards a population based model that addresses the underlying causes, which is in line with upstream thinking. 5,8,14,18 Despite the many successful outcomes to date with these STMMs, the partners have become increasingly aware that the current model of care in Nepal is unsustainable due to the almost complete on-going reliance on the Canadian and American NGOs. Thus, there has been discussion between the partnering NGOs about a refocus on health development projects and host staff initiatives within Nepal.
Lasker's sixth principle describes how to "integrate diverse types of health services," to avoid the issue of siloed care, which focuses on only specific diseases, areas of interest, or types of services. 5 The STMMs provided primary medical and dental care, yet further integration of these and other services within the local Nepalese health system should be considered. Therefore, the integration and collaboration of a variety of services from volunteer and host organizations has the potential to move away from "isolated, episodic interventions" to a "global network of shared learning and positive innovation." 16 The seventh principle to "build local capacity" emphasizes the importance of bidirectional learning and training. 5 In this case study, this could include training host country staff, including local community health care workers, to ensure the ongoing delivery of healthcare once the international volunteers have left. For example, currently, the STMM international volunteers work alongside local interpreters in Nepal who assist them in communicating with the patients. In the future, for example, the Nepali interpreters could be involved in the development and implementation of culturally appropriate health seminars. In addition, as a result of the relationships built during the many STMMs, two of the Nepali interpreters are now being sponsored by the international NGOs to complete their nursing education in Nepal.
Further, there is established local capacity in serving rural Nepal through partnering with the Female Community Health Volunteer (FCHV) program. 11,19,20 The FCHV program has received recognition for their work towards advancing health equity and gender equality in rural communities of Nepal. 11 More recently, there has been a call for restructuring this program to aid in the implementation of the sustainable development goals (SDGs). 11 In this case study, the redirection from aid to development aligns well for future capacity building with the FCHVs program.
The final two principles are "strengthen volunteer preparation" and "have volunteers stay longer." 5 According to Lasker, strengthening volunteer preparation, entails pre-departure training including information about the unfamiliar environment, culture, and work that the STMM volunteers may encounter. 5 Many of the Canadian and American NGO volunteers were returning to Nepal, so less emphasis was placed upon volunteer preparation. However, before every STMM, four pre-departure meetings are held by the Canadian NGO which include basic cultural and religious competencies, language, common diagnoses, and treatments. The lack of a structured and agreed training for volunteers for STMM remains a significant issue for volunteers, particularly because of diverse backgrounds and global health competency levels. Other scholars found that limited preparation about community development principles significantly impacts the volunteers "perceived effectiveness" of the STMM. 21 A call for structured volunteer preparation has the potential to strengthen health outcomes to meet SDGs and to have a greater understanding and ability to apply Lasker's principles. 5 In addition, in these faith based STMMs, a deep understanding of the religious and political climate is important. For example, religious conversion is illegal and acts such as prayer can result in imprisonment for both the visiting volunteer and recipient of prayer. Therefore, it is very important that the STMM purpose is clearly defined and understood by the volunteers.
Finally, "have volunteers stay longer" describes the need for long-term and more consistent STMM trips. 5 Other scholars have also questioned the value and efficacy of trips under three weeks and even up to six months to one year. 21 In the past, this STMM has been two weeks in length. Currently, this appears to have been welcomed by the Nepalese host organization in that they have continued to invite the Canadian and American NGOs. This STMM, however, might be strengthened by ensuring that the host community in Nepal be involved in open discussions about future STMM trips, including potential for the international volunteers to stay longer or come more frequently.

Discussion
The above application of the principles developed by Lasker has demonstrated one way in which a collaborative relationship between NGOs may be guided by taking into consideration the host perspective. Such principles may thus be viewed as a strength, with the intention to ensure that there is mitigation of harm and that benefits are maximized.
Critically considering the host community perspectives has increasingly been an emerging area of research. 7,16,17,21,22 Others have explored host perspectives on student trainee competencies in a short-term experience and found that the host respondents rated respectful conduct and cultural awareness as important. 17 In addition, the majority of the host respondents stated that fluency in the local language was not as important. Also stated was that the purpose for understanding competency expectations for trainees was to work towards improved global health curriculum design and pedagogy, to develop experiential learning, and to better meet host expectations and goals. 23 In addition, they emphasized the importance of working towards mutual trust and respect, ethical sharing of power, and creating a collaborative agenda. 22 A systems thinking approach to shortterm health missions is proposed to assist with the ongoing, iterative process of self-organization and mutual learning. 16 In a survey of a convenience sample of 288 volunteer partner organizations located in 68 countries, highly skilled volunteers working a shortterm abroad trip were found to be most effective at promoting nutrition and healthcare, followed by slightly less-skilled long-term volunteers. 21 In addition, they found that there was greater variation in the perceived effectiveness of the volunteers based upon their ability to speak the local language, followed by their skill level and length of service abroad. Lastly, they found there was a perceived effectiveness if the volunteers had training in community development principles and practices.
Scholars also were interested in determining how organizer practices aligned with the host community preferences while on STMMs. 7 They administered an online survey with 334 STMM organizers and conducted interviews to explore existing practices. Similarly, with host community staff, they collected 49 survey responses and conducted 75 interviews. They found that organizer practices often did not align with host community preferences. This finding supports the importance for STMM organizers to ensure their practices align with those of the hosts.
Building upon her work on the development of the principles, Lasker and others conducted a scoping review of the literature, analyzing the implementation of 27 guidelines for STMMs and how these guidelines relate to the desires of host country staff working with volunteers. 14 They found that most existing guidelines were predominately developed in sending countries of the Global North and specifically addressed practitioners and educators. 14 There appeared to be general agreement for certain key principles, such as proper preparation and supervision of visitors, a need for effective, responsible, and ethical programs for host partners, adherence to pertinent ethical and legal standards, and needs assessment and evaluation. In addition, host country staff in these studies added that mutual learning and respect for the hosts were also extremely important. The findings of mutual learning and respect for the host community supports the aims of others researching in the area of host perspectives for trainees. 22

Lessons Learned
The lessons learned from this case study highlighted the importance for using a guideline or a framework to foster mutuality between the visiting volunteers and host-country by maintaining continuity of programming, by including hostcountry involvement in what is required, by building capacity, and by preparing volunteers to have a positive global health volunteer trip. In conclusion, the retrospective application of these principles by Lasker between three NGOs provided additional beginning insights and understanding of how to approach volunteer global health trips, with the potential for fostering mutual learning towards the attainment of the SDGs.

Recommendations for the Future
Using a guideline or framework such as the Principles for Maximizing the Benefits of Volunteer Health Trips can be a useful guide for the various stages involved in a STMM from the initial preplanning, volunteer preparation, participating on the ground, and post trip. The critical importance for including the host perspective in determining how best to align the volunteer activities with the host communities' preferences has been acknowledged. The implementation of such guidelines would seek not simply to provide aid but to provide development, to move from a model of doing-for toward catalyzing and empowering the host community to be able to do so themselves. Implementation would ensure moving away from a colonial or imperialist model, towards collaborative and effective standardized guidelines, focused on host preferences versus volunteer desires for STMMs, and other global health volunteering. 23