The goal of this research was to identify the particular role of short-term medical missions and to address some of the issues that surround them within the context of health care in Honduras. However the actual identification of the role of STMMs, that of health service providers, became evident early in the research process, and the data collection and analysis therefore became a broader exploration of that role. In particular this thesis has analysed some of the reasons why STMMs have taken the role of service providers in Honduran health care, and the actual and potential consequences of using STMMs as health service providers.
The Role of Short Term Medical Missions
It is clear from looking at Honduran health statistics and from the data collected during this study that Honduras faces major issues related to health and health care. Overall the health status of Hondurans remains poor, with children suffering disproportionately from ill health related to poverty. The incidence of infectious diseases and malnutrition reflect the poor housing, sanitation and water supply, uncontrolled vector occurrence, unemployment, low educational achievement and poor access to health services faced by many Hondurans.
While Honduras has a well-structured health system in place, there are significant gaps in the system and access to health services remains a major issue. The Honduran health system has been criticised by international agencies as being functionally unsound, unable to deliver comprehensive protection to individuals or communities and fragmented, with poor co-ordination and referral systems. The results of this became clear during the research, as patients and local health professionals highlighted problems with access to services and the resourcing of public clinics. One of the most concerning issues for Hondurans was their inability to obtain even basic medications. Although the public health system is supposed to provide medication for free following consultation at a centro de salud, the centros are frequently under stocked and often completely run out of medication.
There is clearly a need for improved health services in Honduras, particularly for the poor and for those living in rural areas. However a history of political crises, structural adjustment programs and natural disasters has left the State unable to meet the health needs of all. This has led to significant growth in the NGO sector, with NGOs now taking responsibility for providing health care too much of Honduras' poor and rural population.
STMMs have emerged as one method by which NGOs and religious groups in Honduras are providing health services. This study has shown that STMMs are clearly what Korten (1990) terms a first generation, or relief and welfare strategy, offering temporary alleviation of the problems faced by Honduras. They have increased in popularity over the past few years partly because they provide “free” services to largely impoverished communities, and they utilise a clearly willing and available resource, Western health professionals looking for a way to “help out”. There appears to be an increasing number of these individuals, both health professionals and lay people, motivated by the desire to do good, by religious convictions or simply for personal reasons, who are willing and able to give a week or two each year to travel to Honduras. The demand for opportunities to work in Honduras has become so strong it has in fact led to the emergence of a new industry, termed “Social Tourism”, which caters to the logistical and tourist needs of these groups.
As a result of the obvious need, and the willing resources available in the form of western volunteers, STMMs are now being used to provide health services across Honduras, attempting to fill gaps in the national health system. The services they provide include assessment and curative services to individuals, resources such as medication and medical supplies to individuals and communities, and a limited amount of health education. Because of their roots in the biomedical model of health, and the limitations of short-term work, the activities of STMMs tend to have a curative emphasis. The key tool of the teams observed in this research, and arguably most teams involved in family or general medicine, was the “clinic” where patients are seen one-to-one or in family groups by a doctor or nurse. Consultations are usually brief, and treatment simple. Most patients are prescribed some medication, often just simple analgesics, vitamins and parasite medication. It appears that very few patients are sent home without being given something. The majority of patients present with only minor complaints, although a few patients may be referred on, where possible, to local health care providers for conditions requiring further treatment.
This research has shown that while the arrival of a team draws large crowds of people, the majority do not come because they are unwell, most come in the hope of obtaining medication not available at their local centro de salud including vitamins and basic analgesics. While the teams see the provision of medication solely as a part of the service they provide, it is often one of the main reasons why Hondurans welcome, even invite, the teams. This applies not only to individuals, but at community and national levels also, where teams are seen as being an answer, at least a temporary one, to the problems of resourcing small and rural clinics.
The use of STMMs to provide health services is significantly limited by language and culture, resources, personnel, knowledge and of course by the short-term nature of the brigades. Language and cultural differences frequently result in mis-communication and limit the effectiveness of consultations and of any teaching. Limited resources and personnel, and local knowledge deficits have significant implications for the quality of care given, however the very nature of short-term medical missions is perhaps the most limiting factor. Not only are teams unable to follow up on individual patients, they are often unable to see and respond to the social, economic and political causes of ill health in the areas in which they work. Preventative actions undertaken by teams are usually minimal, often limited to short teaching sessions and the giving away of toothbrushes, shoes and vitamins. Because of these issues it has to be considered that STMMs may not be the most appropriate means of meeting health needs. As a relief mechanism they are well suited to meeting short term needs where the health system is unable to cope, although the evidence suggests that at best teams are able to offer only immediate attention to minor and temporary ailments. The limitations outlined in this thesis have led some to conclude that the teams do not make a significant improvement to health in the communities in which they work, and in fact may actually have a negative impact. Some have gone as far as to accuse teams of malpractice.
While this research did not directly address the issues related to the impact of STMMs on the health status of Hondurans, it did raise some important potential and actual consequences of the use of STMMs as health care providers. In particular the issue of dependency was identified. Data collected during the course of this research indicates an increasing level of reliance on short-term teams for the provision of care to the poorest and to rural areas, at local and national levels. While there is no evidence that the functioning of the Honduran health system is actually dependent on STMMs, there is clearly an expectation that team can and will provide services. This dependency is shown quite clearly shown in the issue of medication provision, where the Secretaria de Salud is often unable to maintain medication supplies to all centros de salud, and therefore welcome teams who arrive with their numerous boxes of donated medication. There is also an expectation from the Secretaria that STMMs are able to provide services to remote and isolated areas that their services do not reach.
The findings of this study also highlight the problem of paternalism, operating from what Parfitt (1998) terms a “vertical approach”, where decisions are made by outsiders, and medicine is given away in a paternalistic manner. This type of approach has been implicated in the development of dependency, and indeed this tendency is reflected in the research. It also is in accord with Korten’s (1990: 141, 143) ideas regarding relief. Relief strategies, in this case STMMs providing health services, do not result in empowerment or self-reliance, but tend to create a long-term dependence on the NGO and the services it provides. STMMs are unable to do anything to remove to causes of poor health, and it is possible that in time their capacity to give assistance may be overwhelmed by growing demand.
Unfortunately it seems that Honduras may be forming a dependency based on an expectation of what they may receive, rather than the reality of what the teams can actually provide. This tendency towards dependency is probably related to the long-term use of a short-term tool, and the emphasis on help coming from outside. Honduras has a long history of dependence on the USA in particular, and the use of STMMs in health care may indeed be a reflection of larger issues of dependency in Honduran society.
Further Questions
It is clear that there are huge needs in health care in Honduras, and as service providers, STMMs are attempting to fill a significant gap. However this study has perhaps raised more questions than it answers. In particular it has raised questions about whether they are indeed actually filling real gaps, and if they are, whether they are the most appropriate means of doing so.
The study results indicate that STMMs are not in fact able to effectively fill the gaps in healthcare that they are welcomed to Honduras to fill. There is some irony in the fact that there is a significant tarmac bias to the locations in which the teams work, despite the expectation that they will offer services to the more remote and impoverished regions which national health services are unable to reach.
STMMs are also largely bio-medically focussed with limited ability to provide the health promotion and education services that are clearly needed. They tend to treat mainly minor ailments, expending a lot of time and effort dispensing Paracetemol and vitamins, while being very limited in their capacity to treat more serious health problems or to provide the long-term treatment and follow up required for chronic conditions. While this study has concentrated on general medical teams, there is unfortunately a clear shortage of surgical and specialist services within Honduras. Further research would be useful to determine the need for and role of specialist teams.
Even where teams are filling gaps, their effectiveness is severely limited by their short term and expatriate nature, and their prolonged use does nothing to empower Hondurans, potentially contributing to issues of dependency and inequality. They are clearly not the most appropriate means of addressing health needs. This raises the question of just what is the most appropriate means to meet health needs in Honduras. On a global level the issues of who should be responsible for providing services, particularly to poor and rural populations, and how and what services should be provided has been widely debated in the international health and development literature. However these questions need to be examined further within the Honduran context, and with reference to what is already happening and what resources are already available.
STMMs are one of those resources available to Hondurans, and as such they are an attractive means of meeting health needs, largely because of their low cost (to Hondurans), their access to resources especially medication and perceived expertise. If the use of STMMs as direct health service providers is discouraged, there is a risk that Honduras will loose this resource. There is clearly a need to re-examine the role of STMMs and to look for a way in which they are able to contribute in a manner that is beneficial to Hondurans and supportive of the Honduran health care system.
The resolution of these issues will not be easy, as it requires thinking beyond the provision of short-term teams, and looking at longer-term issues of sustainability and the appropriate use of resources. While it is beyond the scope of this study to examine potential solutions to these issues it is my opinion that there are a couple of paths that could offer a way forward. At an organisational level these include the integration of teams into longer-term projects, as some organisations are beginning to do. Professionals wishing to work in Honduras on a short-term basis should be appropriately trained and directed to existing projects where their individual skills can be best utilised, and where their practise in such an unfamiliar environment can be monitored.
Resolution of these issues will also require discussion at a national level and the involvement of the Secretaria de Salud. Current policy at the Secretaria is focussed on encouraging the teams with little energy spent on monitoring or evaluating the impact they have. The ideal resolution is of course an improvement in national health services, removing the gaps teams are being asked to fill, however this is probably unlikely without large scale, structural change. In the meantime a more proactive approach to monitoring the teams and to encouraging long term over short-term solutions would go some way towards improving the situation. As Oken, Stoffel and Stern (2004) have noted STMMs may be best able to make a lasting impact if they become integrated into local public health and rural development systems.
Finally there is need for increased discussion of these issues between the organisations who bring teams, and within academic circles. Although some commentators and practitioners have begun to look more closely at this issue (Montgomery, 2000; Oken et al., 2004), this work tends to be focussed more practically, on how to improve missions rather than rethinking the entire paradigm in which they work, and most of it is non-academic in nature.
While STMMs continue to plug gaps in the health system in Honduras, it is vital that these questions raised in this research are addressed. Just what is the most appropriate means of providing health care in Honduras? What is the best way Hondurans can use the willing and available resource represented by STMMs? If these questions are not addressed and STMMs continue to be utilised as Service Providers, without integration into longer-term programs, the implications for the health of Hondurans and for the Honduran health care system may be significant.