Health Volunteers Overseas: A Model for Ethical and Effective Short-Term Global Health Training in Low-Resource Countries

Global Health Workforce Shortage

There is a global shortage of health care providers, and it is estimated that it will reach 18 million by 2030.⁷ This deficit disproportionately affects LMICs, where the burden of disease is highest and the ability to educate and support the health workforce is limited. These environments do not have enough health care professionals, few of the professionals have the opportunity for continued professional education or subspecialty training, and many work in isolation with large patient loads and limited resources. The “brain drain,” in which clinicians from resource-poor countries emigrate to higher-income countries, further exacerbates the shortage. Health worker performance in LMICs also remains a challenge to delivering high-quality, evidence-based health care.⁸ Yet, a well-trained and appropriately deployed global health workforce is essential to achieving universal health coverage, economic growth, and the United Nations Sustainable Development Goals.^9–11

Standards for Short-Term Global Health Engagement

Guidelines for short-term global health engagement typically start with the principles of beneficence and nonmaleficence,¹² or “do no harm,” while also enumerating certain principles or recommendations. For example, a 2018 American College of Physicians paper identifies 5 positions, including predeparture preparation as an ethical requirement, in and of itself.¹² A 2017 Pediatrics article summarizes 10 recommendations for trainee and clinician preparation, including exploring personal motivations, avoiding “poverty tourism,” and ensuring that professional goals are clarified and aligned with host goals. The authors call for the establishment of preparation standards in partnership with both sending and host institutions.¹³

An article from the host institution perspective, published in BMJ Global Health, addresses expectations for international visiting faculty including developing mutually agreed-upon goals and careful selection and preparation of guest faculty to meet host's goals. The authors give the following instruction¹⁴:

You plan the time the person should be here and when he/she is needed most, and you plan the curriculum and the topics. So they also come prepared and send someone who is an expert.

Research from a 2018 Globalization in Health study defines the following 6 core consensus principles for effective and ethical short-term global health activities: (1) appropriate recruitment, preparation, and supervision of volunteers; (2) host partner, who defines the program and their role in it; (3) sustainability and continuity of programs; (4) respect for governance, legal, and ethical standards; (5) regular evaluation of programs for impact; and (6) mutuality of learning and respect for local health professionals.¹

The next section of this article focuses on how the HVO short-term global health engagement model operationalizes best practices, similar to the guidelines discussed above, in a systematized, effective, and financially sustainable approach. This approach has been replicated and adapted within HVO itself, enabling the organization to grow from initially addressing just 1 area of clinical training, orthopedics, 33 years ago to 18 different clinical areas today (Table 2). This model can be implemented, in whole or in part, by other organizations or entities seeking to address global health training needs in cost-effective and ethical approaches.

Overview

HVO programs address both the shortage of health workers and the quality of care delivered in LMICs by teaching, training, and mentoring health care providers, including faculty, residents, and students based in hospitals, clinics, and universities (Supplement 1). Since its inception, HVO has focused on teaching rather than service delivery, although its St. Lucia site centers on clinical care provision. To achieve its mission, HVO sends highly skilled, short-term volunteers to teach in projects that are designed with host partners and articulate clearly defined goals and objectives, as well as monitoring and evaluation processes. The organization's health worker capacity building approach is distinguished by 3 core attributes: efforts are education focused, volunteer driven, and partnership based.

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A volunteer provides training in hand surgery at Health Volunteers Overseas' project in Kampala, Uganda. © 2018/Health Volunteers Overseas

• Education focused: HVO is committed to providing education that builds health worker capacity and promotes exchange of knowledge and skills between health care provider peers. It develops partnerships with host institutions that address their long-term training needs and priorities. Project design is guided by local diseases and conditions, and the projects are relevant and realistic, focus on prevention (when appropriate), promote lifelong learning, and identify and train local personnel who will assume the roles of both educator and provider.

• Partnership based: HVO establishes ethical and mutually beneficial partnerships with host institutions—hospitals, clinics, and universities—to provide education, training, and mentorship. A set of key principles serves as the foundation of HVO's partnership model, including mutual goal setting, honest and open communication, equity, mutual benefit, active partner engagement throughout the project life cycle, flexibility, and clearly defined leadership roles. Another key component is identification of a local champion who can inspire and motivate others, help maintain project momentum, and guide partnership evolution.⁶

• Volunteer driven: Project implementation is ensured by a small staff and a large cadre of volunteer health professionals, based both in the United States and abroad, who serve in clearly delineated roles. Annually, an estimated 600 volunteer health professionals serve with HVO as teachers, project directors, steering committee members, or on-site coordinators, supporting more than 90 projects in approximately 25 countries. Roles are defined in HVO's Leadership Manual and Guide to Starting New Projects as well as in agreement letters signed with each site when projects are established.

Human Resource Infrastructure

The HVO model has a unique and cost-effective human resource infrastructure that assures project management and oversight, enabling effective short-term global health engagement. Key stakeholders include staff, volunteers, project directors, on-site coordinators and steering committee members.

Staff administer the volunteer management system, implementing processes to ensure timely and on-target project activities. Staff serve as the communications, coordination, and support nexus for the organization.

Volunteers are fully licensed health care professionals from private practice and academic settings who teach, train and mentor students, residents, faculty, and other health care providers in 2-week to 1-month assignments, depending on the site. The annual number of volunteers needed at each project site is assessed based on feedback from clinical leadership. HVO strives to identify and send the requested number of volunteers and measures progress toward recruitment goals annually.

Some HVO project sites can also accommodate residents, if they are accompanied by a preceptor. Volunteers are responsible for funding their own airfare and accommodations although HVO has several grant opportunities to defray these costs including the Orthopaedics Traveling Fellowship and the Plotnick Nursing Education Volunteer Fund. Approximately 28% of 2018 volunteers received partial funding to support their overseas assignments.

Project directors are experienced health professionals whose responsibilities include project design and monitoring, volunteer selection and orientation, and technical oversight. They help prospective volunteers set realistic expectations, understand site needs, and thoughtfully prepare for assignments. Project directors submit annual surveys outlining accomplishments, challenges, and new initiatives, and they are expected to be in regular contact with their sites, including visiting, to stay abreast of important changes and issues.

On-site coordinators are selected by host partner institutions for each project. Some HVO project sites identify both an administrative as well as a clinical coordinator, who is typically a senior faculty member or department head. Administrative coordinators assist with visas, arrival arrangements, and housing issues, liaising closely with HVO staff. Clinical on-site coordinators identify training needs; approve, schedule, and orient volunteers; and provide feedback on both volunteers and evolving project needs through informal and formal mechanisms, including an annual survey. Their level of engagement depends on individual motivation and availability and thus varies from project to project, which can affect project quality.

Steering committees provide programmatic oversight for each of the 18 clinical divisions. Each steering committee is composed of 3–10 volunteer health professionals who approve new projects and review existing projects (and, when appropriate, suspend or close projects); set policy on the types of volunteers who can be placed; help to recruit new members and volunteers; and plan workshops, meetings, and other outreach activities. Steering committee members are selected with input from HVO staff and current committee members, based on criteria such as commitment to teaching and training, availability to participate in 1 or 2 meetings per year, and global health experience.

HVO volunteers, project directors, on-site coordinators, and steering committee members are volunteers who donate their time and expertise to the organization, receiving no compensation for their efforts. In 2018, the value of services donated to HVO totaled approximately $6,743,500.

Volunteer Management System

Over 3 decades, HVO has developed —and continues to refine—a volunteer management system that enables highly skilled health professionals to make incremental but sustained improvements in the availability and quality of care delivered in low-resource settings. Each volunteer's teaching assignment contributes to stated project goals and objectives and builds upon the previous assignment. For example, a team of 5 HVO volunteer nurse educators worked with nurses at Hue University of Medicine and Pharmacy in Vietnam who wanted to expand their research capacity. Together, the nurses developed a 2-year plan for their research agenda, which included education about research methodologies, grant writing, and publishing in peer-reviewed journals. Each HVO volunteer nurse educator knew what she was expected to teach to advance the collaborative plan, and the Vietnamese nurses were confident in achieving their goals and advocating for needed resources.

In any given year, 40% of volunteers have completed a previous HVO assignment. Some return to the same site, providing teaching continuity, while others volunteer at new sites. Repeat volunteers can also share insights and techniques learned at one site and bring this information to new sites. In this way, HVO's short-term volunteers help expand a network of professional peers who sometimes continue to engage long after a volunteer leaves the host institution.

HVO is sponsored by 18 professional associations (Supplement 2), including the American Academy of Pediatrics, the American Society of Clinical Oncology, and the American Physical Therapy Association. These associations provide invaluable access to their membership, which serves as a primary volunteer pipeline for our projects, while HVO provides sponsors with structured teaching and training assignments and the opportunity for their members to participate directly in their specialty's global health community.

Key Processes

HVO's volunteer management system includes 4 key processes, as described below. An array of resources support these processes, ensure quality implementation, and enable organizational learning. These HVO resources include the comprehensive Guide to Volunteering Overseas, Leadership Manual, Guide to Starting New Projects, and KnowNET, a password-protected intranet for volunteers and project directors that provides volunteer schedules, teaching resources, and policies on research and donations of equipment and pharmaceuticals.