International guidelines for the successful organisation of humanitarian medical missions (HMMs) during peacetime

Introduction

The development of these guidelines on the conduct of a humanitarian medical mission (HMM) is a direct consequence of the International Conference on Humanitarian Medical Missions (ICHMM). This inaugural meeting was held in Singapore from 30 October to 1 November 2014. It attracted the participation of over 300 delegates from 17 different countries around the world (see Appendix 1 on profile of delegates to ICHMM).

The scope of this ICHMM conference was confined to peacetime medical missions of an elective nature in response to specific requests for humanitarian aid and also to natural disasters which occur on an ad hoc basis. The organisers of this inaugural ICHMM meeting realised that the field of humanitarian aid is vast and encompasses areas such as global epidemics, wartime scenarios and the problems of starvation and refugees. In order to do justice to the stated goals of this conference, the programme of this three-day meeting focused specifically on the multi faceted aspects of the organisation of peacetime HMMs. Hence, the guidelines developed pertain to elective humanitarian medical missions and not to other situations regarding humanitarian assistance.

Prior to the conference, a questionnaire on HMMs was sent to seven different organisations and well-known individuals involved in humanitarian work. The results of this survey (see Appendix 2) formed the basis of these guidelines as well as the deliberation of an international panel held on the third day of the conference, dealing with the specific topic of developing guidelines.

The ICHMM conference was dedicated to ‘volunteers beyond borders’ in the firm belief that volunteers are the lifeblood of all HMMs. Volunteers are motivated by a sense of charity, compassion and altruism towards those who belong to the more vulnerable and disadvantaged groups in society.^1,2

Requests for humanitarian aid

The requests for humanitarian aid can come from a variety of sources. They can arise from individuals working in a third-world country, from an institution which has a specific need to upgrade a service or a department, or a direct request from a health ministry. Occasionally the request can come from a non-governmental organisation (NGO) such as a religious or a service organisation. In the vast majority of cases as shown in the survey, requests came from individuals or government/private institutions. It is important that HMMs should take place in response to a request for aid and not out of personal desire to carry out altruistic humanitarian work per se.

Organisation of an HMM in response to a request

The response to a request depends largely on whether the request is directed at an individual working privately or within an organisation. The request can also be directed at a well-known welfare organisation, a foundation known for humanitarian work such as Singapore International Foundation (SIF) or to a government agency.

An institution such as the Singapore General Hospital (SGH) or a tertiary hospital should preferably have an official corporate social responsibility (CSR) programme which can respond to requests for humanitarian aid or to disaster situations. This corporate philosophy of extending medical services beyond ³ the shores of the nation is to be encouraged because it is laudable and global in outlook. It will provide a platform for medical, nursing and other personnel working within the institution to be able to respond as volunteers. The provision of corporate volunteerism leave is important in encouraging staff of institutions to volunteer their time and service for official missions and/or community development projects in third-world countries.

Once the institution has approved and endorsed a mission to proceed, then the challenge of organising a team will fall on the shoulders of the leader of the mission. The team leader is a key figure in getting a cohesive team together, to coordinate with the requesting individual or institution and to gather the necessary resources to ensure the success of the mission.

Funding of an HMM

This is perhaps the most challenging aspect of organising an HMM because the team needs to be transported to wherever the request has come from. Supplies and medicines have to be purchased depending on the type of mission to be carried out. If they are purely educational, then this will not be necessary. An institution such as SGH with a CSR programme may have an annual budget set aside for such HMMs. Otherwise, the team leader will need to source funding from philanthropic organisations, service groups, NGOs such as Rotary and Lions and individuals. As much as ‘volunteers’ are the lifeblood of an HMM, funding is the key to its success.

The survey carried out showed that volunteers usually come up with their own funds most of the time. Philanthropic organisations and NGOs provide funding some of the time and government institutions only rarely set aside funding resources for these HMMs (see Appendix 2).

Organising a team and team composition

This will vary considerably with the nature of the request. It can be an individual specialist whose expertise is needed or it can be a complete multi disciplinary team comprising doctors, nurses and allied healthcare personnel. Most surgical teams will consist of a surgeon, an anaesthetist, nurses and, for cleft missions, an orthodontist and a speech therapist will be included as part of the team.

The team leader is usually chosen by consensus because of his or her experience not only in the speciality but also for leadership qualities. During missions in foreign countries, it is sometimes inevitable that the team may have to deal with emergency situations like shortage of water and electricity, transport difficulties and even sudden onset of local conflict where evacuation of the team may be needed for safety reasons. The members of the team must be chosen with due care because the cohesiveness of the team is an important factor for the success of the mission. Unexpected challenges sometimes arise in the midst of a mission and the team has to be able to respond in unison to overcome these adversities.

The issue of bringing medical students, trainees and lay individuals as team members during an HMM needs to be addressed. An elective medical/surgical mission is slightly different from a team for a natural disaster situation. A requesting individual/institution expects the best from the visiting team of experts. SGH has always believed in bringing the best of Singapore medicine to requesting institutions abroad and in treating local patients as though they were SGH patients. Hence, the SGH corporate philosophy has always been to send our consultants as experts and if trainees come along, their responsibilities are identical to the SGH situation. In the survey, it is interesting to note that the majority of sponsoring teams will bring students, trainees and lay individuals only some of the time. The usual reason given for their inclusion is to give them the experience and exposure of an HMM team in action. This is fine so long as their responsibilities do not exceed their capabilities. Otherwise, this may lead to unwanted outcomes. HMM missions are after all a humanitarian exercise with a high element of goodwill between donor and recipient parties, and everything possible must be done to ensure positive outcomes.

Protection of team members

The countries being visited by HMM teams are usually in the third world with known epidemics of malaria, dengue fever and other emerging viral diseases. The team leader needs to find out the latest health reports in the country to be visited. Team members need to be correctly advised on taking appropriate health precautions. In addition, they should be covered with medical insurance as well as travel insurance. SGH provides for all staff members going on an officially endorsed HMM not only official leave of absence but also their travel insurance. This enlightened policy to take care of the staff on a HMM will encourage staff to give their best as volunteers. In the survey, it is interesting to note that not all teams are provided with medical and travel insurance and appropriate vaccinations all the time (see Appendix 2).

Quality assurance (QA) and outcomes documentation

This is an important aspect of HMMs which has not been sufficiently emphasised. This lack of emphasis is partly due to the nature of humanitarian aid and assistance which are provided voluntarily and given without any consideration of financial returns. Hence, it is difficult for QA and outcomes to be enforced, but nevertheless, there is a need for HMMs to be accountable to the donor and recipient institution, to make sure that expectations are met and to be accountable in the event of medico-legal complications. These QA measures are best implemented when they are self-imposed and all individuals and teams understand that they have an unwritten ethical obligation to ensure the safety of all patients treated by them during an HMM and to be totally responsible for their actions.

In the survey carried out (Appendix 2), all the surgical teams obtained consent for operations and maintained individual case notes of all their patients. Photographic records were kept by most teams and follow-up visits usually were carried out by half of the teams. Reports of HMMs were compiled for the sponsors/home institutions by a minority of the teams.

The concept of accountability is poorly defined in many humanitarian organisations as concluded by Tan and Von Schreeb in their paper ‘Humanitarian Assistance and Accountability’. ⁴ There is a lack of emphasis on accountability to recipients of humanitarian aid. This should be an important aspect of guidelines for all HMMs.

Education and training during HMM

The survey results showed that most HMM teams are engaged in patient care (70%) and educational activities (30%). The training of the local team is for sustainability. The aim should be directed at enhancing existing programmes rather than to create something new. ⁵ The capability of the local staff being trained should be carefully assessed and the training tools should be practical in the local setting. When the focus of the team is on a specific area of need, e.g. training midwives to reduce perinatal mortality rate, or establishing a multi disciplinary team for cleft lip and palate care, then the chances of success in the training and service goals of the HMM mission are enhanced. The methodology of training and skill transfer will rely mainly on hands-on training in the operating room and less on didactic lectures or tutorials (see Appendix 2).

Anticipation of difficulties and limiting factors

Most HMM teams face the problem of funding and this is a perennial issue. Funding is required mainly for the costs of travel and the purchase of medical supplies and equipment brought by the team. Accommodation and costs of local transport are usually borne by the hosts but HMM teams must be prepared to pick up the bill for these as well. Forward planning months ahead of the mission will usually eliminate problems of travel and visa application. Informing relevant authorities in the host country ahead of time will help to smoothen the process of customs/immigration clearance at points of entry for medical equipment and supplies. These problems may sometimes arise and cannot be totally avoided. A calm demeanour and patience on the part of the team will be helpful under these circumstances.

Attributes of a good volunteer

For all humanitarian medical missions, volunteers play a pivotal role, hence the dedication of this inaugural ICHMM conference to ‘volunteers beyond borders’. The recruitment of the ‘right’ volunteers is crucial to the success of a mission. Medical volunteers are primarily agents of change. They are concerned about the welfare of others and want to play a part in ensuring that they improve people’s health and quality of life. While on a mission, they readily adapt to new conditions like harsh weather, a new culture, a new language, new food and even a new lifestyle. The primary objective is to make a healthy difference in the health sector. They are driven by the passion and the zeal to bring about positive health changes and their commitment to making a difference is relentless. As a result, they inject a new dynamism into the medical mission. They carry out people-driven intervention on health and on human lives with the vision to create a healthier world in which everyone enjoys a right to a life of dignity and wellness. The ultimate goal of a medical volunteer is to make the greatest possible impact on the causes of debilitating illnesses which incapacitate humanity. The job of a medical volunteer becomes even more meaningful when he or she is able to help the poor and the excluded to take charge of their lives and to eradicate debilitating illnesses. Therefore, medical volunteers must be team players who are brave and ready to take risks. They must aim constantly to promote, protect and to save lives, caring less about what they get out of a medical/volunteer mission. Finally, he or she must be a patient and selfless humanitarian who is ever ready to go anywhere that duty calls. ⁶

Recipe for success of a medical mission – the “dos and don’ts”

SIF utilises four key principles to ensure success of medical missions. ⁷

Volunteer orientation should include an appreciation of the goals of the mission and knowledge of the local customs and culture of the country to be visited. Humility is a keyword and volunteers have to bear in mind that they go for HMM to impart not a ‘superior’ set of skills but a ‘separate’ set of skills. Volunteers may face linguistic and cultural barriers to work effectively, so patience has to be exercised and to ensure that their presence does not put further strain on the delivery of services and building capacity. In terms of training and orientation, volunteers should be involved in the planning process, attend briefings and also participate in fundraising efforts for the mission.

Guidelines for HMM – a checklist^2,8

Conclusion

There are many NGOs around the world performing humanitarian work, usually in less-privileged communities and bringing medical aid and relief to countries where healthcare is deficient or totally lacking. To organise these volunteer medical missions requires tremendous manpower and financial resources. There are many logistical issues and other problems which are encountered at both the organisational level, as well as during the execution of these missions. One of the stated goals of this inaugural conference was to come up with a set of guidelines which will be of assistance to budding healthcare volunteers who wish to embark on HMMs. Based on the input of many experienced volunteers and humanitarian organisations and the results of a detailed questionnaire, the authors have compiled a set of guidelines which they hope will be useful and will lead to the successful conduct of HMMs during peacetime.