BY: JOEL GILBERTSON, JD, MPH
Each time I participate in a health care mission trip to Guatemala, I become more aware of what we take for granted in the U.S. On my most recent visit as part of a surgical relief team, it was mobility — specifically wheelchairs — that I mentally added to my list.
We came to Retalhuleu, Guatemala, in part to assemble 100 wheelchairs and give them to people who needed them. As I watched patients arrive for evaluation at our partner hospital, I was overwhelmed by what the people with mobility challenges went through just to get to our door. Some came in the arms of family members. Some came in the beds of wheelbarrows. Others had to crawl.
"Manuela," in her 30s, was the first patient I met. She began to lose mobility seven years ago due to rheumatoid arthritis. She can't walk and can barely use her hands. As a result, she told us, she stays at home, depending on family members to carry her from room to room. She had come for an assessment to see if she could have a wheelchair.
The wheelchairs — provided by Free Wheelchair Mission of Irvine, California — are unique. They are designed specifically for rural village life in the developing world, outfitted with bicycle tires, a built-in wrench to adjust the frame and a tire pump in case of a flat. One of the many lessons I learned from our clinical volunteers is that what seems like a simple solution for patients who can't get around by themselves — giving them a wheelchair — must take into account complex factors that are part of everyday life for those who are poor and vulnerable in another country. For example, if a physically disabled person has pressure ulcers or bed sores from constant sitting and lying down, a custom-fitted wheelchair will only make the condition worse, which could lead to more serious infections. Or, if a patient has some use of his or her legs and can move with a walker, constant sitting in a wheelchair may result in the legs losing whatever strength and mobility was left.
Telling someone in search of a wheelchair that he or she can't have one was difficult — but we had to be very careful not to do more harm than good.
Manuela proved to be a good candidate, and our physical therapists measured her hips and legs, making the necessary adjustments to the wheelchair to achieve a perfect fit. It was a great moment to see Manuela move around a room independently for the first time in years.
I was on wheelchair assembly duty all week and had the privilege of seeing many more people receive newfound mobility — a young girl with a bright smile who had lost her leg from cancer, a man with mobility problems caused by polio, a man who fell from a tree, a senior who suffered a stroke.
The causes of disability and disease around the globe are many, but there are several key drivers: poverty, malnutrition and lack of access to clean water or appropriate medical care. At Renton, Washington-based Providence Health & Services, part of Providence St. Joseph Health, we have come to understand that when we reach beyond our borders through direct service experiences, we also must discern and respond to the root causes of health disparities.
In global health endeavors, we have realized that doing something that doesn't maintain long-term value is not always better than doing nothing. The typical quick-fix approach does not offer the structural depth and cultural expertise necessary to make lasting improvements. Providence's international programs, therefore, are innovating by investing in systemic change deep within a remote region of Guatemala, guided by measurable results. In some ways, it is population health in action, and we have gathered learnings over the past four years that we hope can serve as a model for other ministries to build upon and potentially improve.
ASKING THE RIGHT QUESTIONS
How does an organization determine where in the world it can make a difference? For Providence, it was important to start with who we are as a Catholic health care ministry. Intending to leverage our scale and resources, we focused on how we could address immediate health needs while also building toward sustainable solutions.
There are many countries in need, but some were a better fit for our organization, especially as we developed criteria for international work, considered what our organization could offer and identified potential partners.
For organizations considering building an international program, understanding not only where you want to serve, but your strategic goals and partnerships, as well, will help determine success. It is essential to develop a list of key discernment questions aligned with the intentions for the work. Providence put together a list according to priorities, differentiating between mandatory and preferred elements. Among the questions during the discernment process, we used these:
- Is there an option to make a multiyear commitment?
- Can we establish metrics for success and monitor data?
- Do our founding Sisters of Providence have pre-existing relationships in the country?
- Are there aligned, in-country partners who can support the work?
- Are volunteer opportunities available for both clinical and nonclinical caregivers?
(At Providence, all employees are known as caregivers.) - Are there in-country nursing and medical education programs?
- Can we strengthen the work with donations from our medical surplus recovery program?
- Is the country politically stable and safe for our volunteers?
- Can we accommodate language needs?
- Is the country within one day of travel?
Informed by our Catholic social teachings plus discussions with industry peers, Providence identified Guatemala as the best fit for our goals and assessment of community needs.
DON'T GO IT ALONE
International work requires formation of strong and meaningful relationships with a network of in-country not-for-profits, hospitals and universities. It is best to begin a partner search by examining existing relationships developed through internal connections, such as caregivers who actively volunteer with global health organizations. Then, potential partners should be screened according to a set of established requirements.
These are the criteria Providence used in choosing to partner with Houston-based Faith In Practice; Medical Teams International, headquartered in Tigard, Oregon; and Universidad Rafael de Landivar in Guatemala City to carry out our work in Guatemala:
- Health programs are sophisticated, with proven results
- Demonstrates effective measurement and quality monitoring
- Uses model of local participation and engagement to empower community leaders
- Structures programs around long-term sustainability
- Manages volunteer teams and international travel logistics
- Willing to accommodate volunteer formation programs
- Flexibility to grow operations as appropriate
- Minimum of 10 years of experience in global health
- History of collaboration
LISTEN TO THE COMMUNITY
After we selected Guatemala and chose our in-country partners, we used a community health needs assessment — just as we would in the U.S. — to better understand the possibilities for service. The assessment, performed by our partners, indicated that 35,000 people live in extreme poverty in the central highlands municipality of Chicamán. The survey identified preventable illnesses, including diarrhea and acute respiratory infection, as the leading causes of death in the area for children under age 5 and widespread chronic malnutrition for those under 2 years old. The survey also showed that access to adequate medical care in the remote region is limited, with a handful of poorly equipped health outposts and only one doctor for every 10,726 residents.
These findings guided our three-year strategic plan to improve key health indicators. The goals focused on outcomes:
- Reduce child malnutrition from 35 percent to 15 percent
- Decrease diarrheal disease from 41 percent to 20 percent
- Increase prenatal care from 22 percent to 60 percent
- Strengthen health system delivery for 35,000 residents
One of the challenges in Guatemala is to effectively balance short-term needs with solutions sustainable over the long term. A responsible approach is community-focused with clear metrics for success, and it involves some of the following integrated programs:
- Infrastructure improvements for homes and health facilities
- Surgical, medical and dental outreach
- Educational exchanges to strengthen family medicine and nursing leadership
- Clinical training for the health care workforce
- Medical supply and equipment donations
DEFINE THE RESPONSE
Our programs in Guatemala are structured around three strategic pillars: public health solutions, medical relief and health system development through education and supplies.
In public health, we financially sponsor Medical Teams International's maternal and child health care program and provide volunteer support for its service projects that align with our goals. Together with Medical Teams International and our volunteers, our public health interventions to date include the installation of 630 sanitary latrines, more than 750 clean-burning and ventilated stoves and 50 clean water projects.
To facilitate community knowledge of good health and wellness practices, Medical Teams International's community health workers deliver health education messages to targeted groups, focusing on mothers of children under age 5 and on community and religious leaders. When done in tandem with home infrastructure projects, these activities support social and behavioral change that, in turn, reduce illness and disease.
To relieve suffering from urgent health issues, our clinicians travel to local hospitals and villages multiple times throughout the year to provide surgical and medical services. Our in-country partner Faith in Practice works with hospitals in Guatemala to ensure that the surgeries are performed in clean, safe facilities and that there will be proper follow-up for the patients after the teams leave. They also evaluate patients to identify those who are the right candidates for surgery and then support their travel to the hospital.
To help create lasting change, we look to our local academic institution partner. We established a relationship with the Universidad de Rafael Landivar as part of our strategy to strengthen the local health system and achieve measurable health improvement. Together, we are building a robust medical education exchange program that provides opportunities for residents and students to serve in both countries. Medical residents from across our health system participate in the university's innovative model of health delivery that involves door-to-door surveying and mapping of health risks. In the U.S., Guatemalan medical students get their first experience with the family medicine model and participate in integrated, multidisciplinary care teams. We have much to learn from each other, and, over time, hope to achieve a sophisticated level of expert-to-expert collaboration that will inspire the next generation of doctors and nurses and help us to better serve our patients.
Providence also is providing a solution for health care resource needs in Guatemala through our medical supply recovery program. Each year we send about $1 million in medical supplies and equipment to our partners around the world, part of our program to recover unused or recyclable products and redistribute them domestically and internationally. Through a warehouse in Washington state, we offer volunteer opportunities for caregivers to sort and package supplies for shipment. We also support individual supply requests from caregivers joining other international service and medical teams.
LOCAL PARTICIPATION
We never assume to know what a community needs. We work with community members who, from their unique cultural vantage point, can define what is most needed and how to make it happen. In turn, we provide them with opportunities to lead the way in improving their own lives. The most effective programs are centered on community participation and empowerment, and, in our experience, there are some important steps to achieving this kind of participation:
- Thoughtfully build relationships of trust
- Identify local leaders and resources
- Recognize the dignity of those living in poverty
- Listen to local residents in order to define needs and solutions
- Honor the complex systems already in place
- Distinguish the limitations of your involvement
Providence makes a significant commitment to this work, not only with financial support for our volunteers, but also through our internal structure. In addition to covering the costs of our programs in Chicamán, Providence pays for more than half of the travel expense and in-country fees for hundreds of volunteers each year. We have found that when we ask volunteers to contribute a small portion of their trip expenses and participate in fundraising, it ensures a personal commitment to this work. We also make a number of scholarships available to individuals for whom the contribution would be a financial hardship.
The international program is part of Providence's community partnerships division, a blend of departments with interlinked goals including philanthropy, government affairs, community investment and environmental stewardship. The division helps areas throughout the organization to support international programs. For example, the government affairs team flags opportunities to advocate for issues that affect global poverty and any available agency funding. In addition, the partnerships division's clinical director provides guidance and advice to each department and helps ensure continuous quality improvement for our educational exchanges.
The structure of unified departments not only helps advance international work but also supports the health care system's overall strategic priorities, with focus on caregiver engagement, clinical quality and expert-to-expert collaboration, among others. The fusion of strategy is reinforced by the international programs advisory committee that includes senior leaders from across the organization.
A senior director leads the international program, and five full-time caregivers manage volunteer programs, educational exchanges, medical surplus recovery and community relations. Providence has a high volume of service trips, and a group of about 30 caregivers also volunteer as team leaders to accompany trips and serve as planning liaisons.
LOOKING AHEAD
Providence is embarking on its third year in Guatemala, and we are currently expanding programs to new communities in the region while also developing a multiyear exit plan. The discernment process for leaving a community is just as important as for entering. The exit strategy should focus on efforts to increase the effectiveness and adoption of health interventions.
We also are scaling up some projects while practicing "rolling experimentation" by testing new and innovative ideas in small batches, such as a new roof water filtration system and a nutritional program that will supplement local food sources with livestock. We continue to monitor outcomes and engage community members in the process, learning where there may be gaps and celebrating progress.
At its root, the work in Guatemala is deeply formational, and it is meant to give the people who work for Providence and our partners an opportunity to learn and grow through these experiences. To provide a formative experience for Providence caregivers, we emphasize our heritage and the fact that Providence got its start as the result of international outreach 160 years ago, when Mother Joseph and four Sisters of Providence journeyed from Montreal to the Washington Territory in the United States. Our international work continues a tradition of compassionate service and solidarity, and we see that putting the Providence mission and international programs in the context of our heritage helps increase caregivers' understanding.
The experience that our caregivers bring back from Guatemala and spread through their circles of influence animates our mission in their daily work and lives. Opinions and cultural reference points often change when we are working alongside those who are living on the margins; rather than doing good for someone who may have less than we do, we are energized to work with one another as co-participants in the same global family. Over time, we believe this sacred work will lead to greater organizational formation and a culture of compassionate global citizens.
JOEL GILBERTSON is senior vice president, community partnerships, Providence Health & Services, Renton, Washington.