The role of short-term volunteers in a global health capacity building effort: the Project HOPE-GEMC experience

Interest in global health experiences has been growing in recent decades. Medical
students are increasingly requesting global health rotations as part of their training
1], and record numbers of medical students are traveling to low-income settings to conduct
research and engage in clinical rotations 2]. Practicing clinicians have also shown interest in this type of experience. Many
have engaged in medical trips to developing countries where their services are sorely
needed 3]. While global health activities have the potential to benefit both the individual
and the host, there can be challenges, and ethical considerations need to be examined
4]. These sorts of rotations can be a substantial burden to the host in the resource-constrained
setting and can have unintended negative impacts on patients, the community, and local
trainees as already scarce resources are shifted to host international visitors.

Further, the relationships between and among institutions and trainees can be unbalanced
as the visitor often comes with supplies and other resources that may or may not be
ideal to the local context. While supply donation seems to be positive, if those supplies
are not locally available or used, these initiatives fall short. Perhaps most importantly,
sustainability is not ensured with these sorts of trips 5]. Many of these global health trips or missions have been described as medical tourism,
when clinicians travel to developing settings and use considerable materials, money,
and logistical and human resources. There are limited data on input, process, or outcome
measures of volunteer clinical missions, and thus, it is difficult to establish any
long-term impact of such interventions. Further, the provision of direct clinical
services by foreign volunteers does not directly build local capacity and is counterproductive
to the development of sustainable health services. Considering that many countries
and communities continue to repeatedly attract medical tourist visits points to a
lack of local capacity building 6].

There are vast needs in developing countries in terms of health capacity building
and vast resources in more developed countries. In this paper, we describe one example
of a way to harmonize the desire of practicing clinicians to have a meaningful impact
on the health care delivery system in a developing country with the structural needs
of a country. We describe the Project HOPE-Ghana Emergency Medicine Collaborative
Partnership which utilizes short-term volunteer physicians and nurses to facilitate
the implementation of a residency and specialty nurse training program in Kumasi,
Ghana. This approach attempts to merge the strengths of developed countries with the
strengths of developing countries to address their self-identified needs. We believe
this model can be useful for others interested in global health partnerships, as a
way to harness the human capacity of short-term medical volunteers to build local
capacity and be a part of a sustainable global health program.

The project HOPE-Ghana emergency medicine collaborative partnership

Ghana emergency medicine collaborative

The Ghana Emergency Medicine Collaborative (GEMC) arose from the recognition that
there was a significant need to increase human resources for health (HRH) in Ghana.
Specifically, there is a need for health care workers with specialized knowledge and
training in managing acutely ill and injured patients. Worldwide data indicates that
injury results in 5.8 million deaths every year—32 % more than HIV, malaria, and tuberculosis
combined 7]. Although this need for specialty trained health workers has been recognized, the
specialty of emergency medicine (EM) is just now emerging in many developing countries,
including South Africa and Ethiopia 8], 9]. Previous efforts to develop health care workers in sub-Saharan Africa have relied
on the model of exporting trainees to developed countries for specialty training,
with many of the trainees staying in their country of training rather than returning
to their country of origin. In 2009, through discussions between the University of
Michigan Department of Emergency Medicine (UMEM), Komfo Anokye Teaching Hospital (KATH),
Kwame Nkrumah University of Science and Technology (KNUST), Ghana College of Physicians
and Surgeons (GCPS), and the Ghana Ministry of Health (MoH), a partnership agreement
was finalized to develop a 3-year postgraduate training program in emergency medicine
for physicians with an aim to improve the provision of emergency care in Ghana.

To provide a trainee with the appropriate tools, training, and supervision to carry
out the task of an emergency physician (EP) takes an extensive amount of clinical
supervision. There is an evolved training process for EPs in the United States. This
process is recognized for producing high quality clinicians, researchers, and educators.
From the very beginning, GEMC was intent on creating a program that would produce
not only sound clinicians but also future educators. To accomplish these goals, there
was a recognized need for clinical educators.

Ideally, a program to train residents begins with a bank of fully qualified physicians
locally to serve as faculty for the program. However, as this was the first program
in Ghana, this was not available. GEMC approached this difficulty by securing international
EM faculty (from the US and UK) to provide the educational and administrative requirements
of the program, requiring a constant on-the-ground presence by US-trained and board
certified EPs. The residents are recruited, supervised, and examined by the GCPS,
the national body responsible for postgraduate medical training in Ghana. The graduates
of the program are therefore fully certified specialist clinicians and educators.
Therefore, those who are being trained by the program will take over the training
of future classes of emergency medicine residents, and thus, the program will, in
the future, be self-sustaining.

GEMC also recognized the need for specialty trained EM nurses to practice with the
trained physicians. Working with the leadership at KATH and KNUST, a 1-year diploma
program in emergency nursing (EN) for practicing nurses was developed. The program
was developed in a “sandwich” format, where students are in-house at KATH for 2 weeks
out of each month and at their home institutions the rest of the time. The EN diploma
program encompasses the full scope of learning activities including didactic lectures,
precepted clinical experience, and simulation laboratory time. The diploma, due to
its unique structure, addresses a specific Ghanaian need by allowing nurses to work
and train concurrently. However, a consistent challenge to making the program a success
includes recruiting, funding, and supporting external faculty willing to spend 3 weeks
at a time in-country. As EM is a new specialty in Ghana, there are very few in-country
experts with formal EN training or experience.

As with the physician training, GEMC has committed to sending emergency nursing clinical
and content experts to Ghana each month for the first 3 years of the training program.
The rate of knowledge transfer, safety of patients receiving care, and overall quality
of care is dependent upon quality, supervised training. Upon completion of the diploma
program, nurses are qualified to take the professional examinations conducted by the
Nurses and Midwives Council (NMC) of Ghana for certification.

Moving forward, the GEMC continues to collaborate with all relevant stakeholders to
strengthen the partnership while promoting career advancement for graduates of the
program. Additionally, the program seeks to establish new partnerships, such as the
collaboration with Project HOPE, to continue providing training to residents and nurses
to continue establishing the numbers of emergency medical care providers in Ghana.

Project HOPE

Project Health Opportunities for People Everywhere (HOPE), the People-to-People Health
Foundation, was founded in 1958 with the mission to achieve sustainable advances in
health care around the world by implementing health education programs and providing
humanitarian assistance in areas of need. Since 1958, Project HOPE has been dedicated
to developing and permanently instituting long-term solutions to pressing health problems
in some of the world’s poorest countries. Today, Project HOPE’s 30+ programs are launched
anywhere from the community level up to the national level and focus on five key areas:
infectious disease, non-communicable disease, the health of women and children, health
systems strengthening, and humanitarian assistance/disaster relief.

Project HOPE began as a volunteer-driven organization, recruiting and deploying medical
volunteers to serve aboard the SS HOPE hospital ship in the 1960s and early 1970s.
When the ship was retired in 1974 and HOPE’s work transitioned to land-based, volunteers
played a smaller role. Since the 2004 tsunami in Southeast Asia, however, HOPE has
once again used large numbers of medical volunteers in connection with their partnership
with the US Navy’s Humanitarian Civic Assistance programs. Today, Project HOPE’s volunteers
not only deploy with the Department of Defense humanitarian assistance/disaster relief
missions but also integrate volunteers throughout the organization, cross-cutting
all five key practice areas within the global health department. For Project HOPE,
the GEMC project is a “volunteer-augmentation program,” where the volunteers deploy
to KATH with an established, preexisting program already in place and operational.
The volunteers’ roles are then focused on enhancing current activities, extending
current services, and building pre-determined organizational capacity using the volunteers’
skillsets and experience.