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The Case for Collaboration Among Humanitarian Surgical Programs in Low Resource Countries Quentin A. Fisher, MD,* and Gail Fisher, MSW†
W
ith burgeoning activity in global health programs that provide training, medical-surgical services, and infrastructure support, participants become increasingly aware of the need for effective partnerships with like-minded and complementary organizations. Effective partnerships are critical in addressing the challenges of fractionation and duplication of efforts, development of meaningful conversations among agencies, and objective evaluation of value and outcome. Alliances are effective when the network of partners is chosen based on their unique contributions and capabilities, and members operate in a coordinated manner, amplifying one another’s capacities. A wide range of appropriate collaborative efforts are feasible for governmental agencies, nongovernmental organizations, academic institutions, and in-country hosts engaged in humanitarian surgical or educational assistance. Donors play an essential role in fostering communication and cooperation among agencies. In addition, transparency, ethical standards, quality review, and valid outcome measurement are universal components of effective humanitarian work.
SCENARIO 1
A short-term surgical mission on its third trip to a site in a low resource country (LRC) finds only a fraction of the expected number of patients arrive for screening. It is learned that another short-term surgical team targeting the same patients recently visited a different hospital in the same city.
SCENARIO 2
For many years, a group of visiting physicians have organized ad hoc teaching teams from their university to visit a LRC hospital at the invitation of a hospital department chair. They have always been warmly received by staff, and their efforts and donations appreciated. During 1 visit, the team encounters a similar group, only to learn both groups, to varying extent, had been replicating one another’s efforts.
SCENARIO 3
An organizational specialist was invited to a major hospital in a populous African capital city to assist on a project to coordinate nongovernmental organization (NGO) activities From the *Department of Anesthesiology, Georgetown University School of Medicine, Washington, DC; *Department of Anesthesiology, Medstar-Washington Hospital Center, Washington, DC; *Department of Anesthesiology, Uniformed Services University of the Health Sciences; and †Resources for Change, Bethesda, Maryland. Accepted for publication October 18, 2013. Funding: N/A. Dr. Quentin A. Fisher and Gail Fisher are cofirst authors. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Quentin A. Fisher, MD, Department of Anesthesiology, Medstar-Washington Hospital Center, 110 Irving St., NW, Washington DC 20010. Address e-mail to [email protected]. Copyright © 2014 International Anesthesia Research Society DOI: 10.1213/ANE.0000000000000053
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from a variety of donor countries. For years, NGOs, visiting scholars, and international agencies had been helping to fill gaps in services, training, and equipment. Hospital staff was sincerely grateful for much of the help but felt the “deluge” was often overwhelming, and that they were displaced in their operating rooms, judged by their sponsors, and saddled with cast-off materials. The hospital director was seeking to coordinate the varied aid programs to better direct the largesse toward what staff knew to be their needs. However, the hospital’s many department chairs had their own arrangements with a variety of outside supporters and researchers, and there was no effective overall oversight or coordination. Some department chairs were reluctant to identify their contacts, fearing they could risk loss of many material and professional benefits.
STATE OF THE ART
In recent years, there has been increased interest and rapid expansion in global health activity by universities, residency training programs, and NGOs.1 Surveys2,3 have found that opportunities for experience in LRCs are attractive to residency applicants in a variety of specialties. Similarly, there has been substantially broadened activity by NGOs engaged in both short-term medical missions (STMMs) and educational support programs. While much is being accomplished in providing services and educational experiences, the growth in global outreach has also been accompanied by demonstrable duplication of services, inefficient use of human and monetary resources, diversion of assets, and imposition of stresses on host institutions.4,5 Many of these drawbacks are tolerated as the cost of doing business in austere settings. Whether the primary goal is to provide care to indigent patients or educate local medical staff, voluntary medical programs invest enormously in planning, logistics, funding, and personnel to assure successful missions. Far lower priority is given to broader nonclinical issues that may impact long-term effectiveness, efficiency, and sustainability. Developing authentic working relationships with complementary and like-minded organizations leads to tackling a broad range of concerns such as mounting surgical missions too close to one another in time or locale; creating overlapping university partnerships within the same hospital and department; or unknowingly, allying with previously unsuccessful in-country partners. With more frequent and sustained international contacts, some LRC hosts have broadened their expectations of what is desirable and possible. Ministries of health may depend on NGOs to fill their infrastructure gaps.6 As the number and frequency of NGO visits to a site increases, so does the complexity for the hosts to effectively utilize those resources, know what to appropriately ask of NGOs, and plan for disruptions to the hospital routine. Adding to the challenge is the fact that multiple in-country hosts may have relationships with NGOs from many different countries. February 2014 • Volume 118 • Number 2
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The overall challenge, in essence, is to seek ways in which in-country hosts can identify their needs, and with their stakeholders cocreate actionable solutions to meet them. Working relationships with host country hospital hierarchy and government officials are not governed by the size or type of NGO. It is as likely that leaders of small groups have good or nonexistent relationships with government ministers and hospital directors as their larger counterparts. Solutions entail going beyond the current paradigm to include the expertise of a spectrum of interests, including the hosts and complementary agencies.7 The following sections examine how effective achievement of stated goals by STMMs and academic partnerships can be positively impacted by considering the larger contexts of NGO activities. Such contexts include: (1) effective partnerships between volunteer agencies and in-country hosts; (2) alliances with complementary and like-minded organizations and in-country authorities; and (3) ethical dimensions in sending teams abroad.
Evolutionary Maturation of Short-Term Surgical Programs
While individuals and small groups have been providing surgical care in STMMs for a long time, the development of larger international surgical programs is mostly a product of the past 2 to 3 decades.8 Initially, the catalysts for many programs were recognition of a need, personal professional contacts, and a vision for addressing a need on a small scale. Over time, many of these small programs evolved into sophisticated, internationally based, and respected NGOs. Still other programs developed as “spin-offs” organized by individuals from large NGOs (“my own NGO” or MONGO).9 Yet, even large, mature organizations may lack professional managers; instead, they rely on physicians with varying degrees of business or organizational expertise or on-the-job learning. At present, STMMs, NGOs, and academic partnerships may be found operating at various points of the spectrum, from small groups using local equipment and supplies requiring considerable improvisation to larger groups with formal administrative infrastructure that are entirely self-funded and able to attract well-qualified specialists for their teams.
GOOD INTENTIONS-HOW IS IT THAT...?
As exemplified by the 3 scenarios above, well-intentioned volunteer groups may find themselves confronting various conundrums as they perform their projects. Competing interests by stakeholders (Table 1) may well lead to problems such as: • sites chosen based solely on personal relationships; • assertive solicitations for aid by host country providers; • sites selected due to greater availability of infrastructure (e.g., hospital beds, operating rooms, services for volunteers, and easy transportation); • donor preference; or conversely, lack of programmatic direction by donor; • failure to clearly articulate goals and expectations or to align them with what is realistic. An issue that has wide-ranging ramifications, but one beyond the scope of this paper, is the role of “personal stake/pride.” Philpott10 examined the significance of gaining status by being a mission volunteer; many host country colleagues also speak freely of the professional stature they have attained by attracting institutions and equipment donations to their facilities. Nonparticipating physicians in host countries may feel undermined by the implied message that they cannot care for their own patients since patients often voice their preference for a foreign doctor.
DEVELOPING SUCCESSFUL, INNOVATIVE NETWORKS AND ALLIANCES
The processes to build networks and collaborations that will strengthen missions and lead to creative innovations must occur both within an organization and among organizations. The basics of developing a successful, high-impact humanitarian program of any size mirror how successful humanitarian programs network to strengthen partnerships among themselves. The principles that apply to “my own NGOs” are also salient for large multinational NGOs. Most important, the success of international alliances hinges on organizations’ strategic objectives and the choice of appropriate partner(s) to meet them. Organizations must look beyond their own capacities and involve others (e.g., NGOs, government agencies, and private sector organizations) whose strengths enhance and synergize their own.
Donors Drive Mission Work
Donors are the engines of voluntary humanitarian work. They include individual and small-group contributors, NGO board members, expatriates, industry sponsors, and government agencies. Donors are concerned about the overall mission, financial efficiency, measured outcomes, and competition from like-minded groups. But in many instances, the donor’s role is largely restricted to funding their chosen mission. When major donors also sit on STMM boards, objective and dispassionate program evaluations are unlikely. With the possible exception of some large donors supporting multinational projects, donors to surgical STMMs have not played a substantive role in inviting NGOs to discuss common goals and challenges. Thus, despite their critical function in promoting the NGOs, donors actually have had little part in directing programs or requiring cooperation among groups.
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Table 1. Stakeholders in Surgical Short-Term Medical Missions Nongovernmental organization (NGO) NGO board of directors NGO leadership Clinical directors NGO employees Volunteers Donors National expatriates Government agencies (may compete for resources) Colleagues who cover the absent volunteer’s duties
Host country Hospital director In-country contact hosts and liaisons Participating professionals Patients and families Nonparticipating medical community Government agencies (e.g. Minister of health, customs) Medical universities National professional societies
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E SPECIAL ARTICLE The process of identifying potential partners is multidimensional. It is characterized by: clearly articulating mutual goals; building strong relationships; contracting for specific areas of responsibility and accountability; and measuring both clinical and organizational outcomes.
uniqueness and differences; listening intently; demonstrating respect; viewing well-managed conflict as productive; honestly acknowledging mistakes and weaknesses; being open to feedback; and being prepared to act on mutually accepted changes.
Partner Selection (Both NGO and In-Country Host)
Contracting: A Successful Beginning Starts with the End
“In developing countries, because of their situation they are more willing to say, ‘yes come on in, we want your help,’ but they may be passive. Without their active involvement and commitment of the host country, the effort is likely to fail.” Seth Berkley, President, International Aids Vaccine Initiative7 Projects exist as partnerships involving individuals, informally organized groups of colleagues, NGOs, hospitals, and academic programs in a variety of combinations. The success of international partnerships requires alignment of the strategic objectives among the NGOs and the in-country interests for the venture. Evaluating the potential for partnership requires mutual consideration of: • mission alignment; • diversity of skills to achieve successful mission outcomes; • partner compatibility based both on demonstrable mutual respect and willingness to align personal agendas in a transparent manner with those of the partnership; • decision-making authority available to all stakeholders; • influence with and access to resources (including stakeholders, government agencies, and community activists).
Relationship Building-an Intentional Effort Toward Meaningful Outcomes
Authentic people-to-people interest, concern, and caring set the stage for all the hard work to follow. Individuals who volunteer frequently excel at all 3. They know the value of good working relationships based on trust, mutuality, and respect. They recognize that it takes time to appreciate the varying skill sets of each team member and to understand how best to work together. Relationship building with the in-country hosts can be no less challenging, even when the NGO is on site by invitation. Successful partnerships acknowledge there are complexities experienced by all parties. In-country providers deal routinely with trying circumstances that demand ingenuity, discipline, and not infrequently, courage. Organizations must be aware of, and avoid, imposing interventions on host communities. At the same time, hosts’ best interests are served by understanding the time constraints of the volunteer organizations and by being conscientious in following through on mutually agreed commitments. Stakeholders can engage most effectively if all involved are aware of, and sensitive to, the antecedent efforts of a proposed project. Equally important is to have an awareness of parallel efforts by other providers. Both within organizations and among network alliances, the characteristics of healthy partnerships include: valuing
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An objection frequently voiced in the humanitarian field is: “We are only volunteers. We don’t want to duplicate the bureaucracy and paperwork we have to deal with back home. We simply want to come in and do a good job.” With understandable eagerness to launch a valuable project, a quickly conceptualized memorandum of understanding may take the place of thoughtful attention to cocreating durable fundamentals. As a result, the need for partnerships to clearly articulate what they hope to achieve, and what their expectations are for each partner may have been left as a tacit understanding. These can lead to mission drift or even untimely dissolution of the relationship. Partnerships that devote attention to strategy, organization, and capability development at the outset, revisiting these periodically, are more successful in their collaboration efforts.11 Robust partnerships develop a clear vision and plan, by discussing the following: • What would success in our work together look like? • How will we measure success? • What are our mutual expectations and responsibilities? • How do we demonstrate buy-in to one another? • How will we specifically help each other? • What will be the timeline for incremental steps toward our goal? • How will we know when our work is done? • How will we know if the current form of our partnership is no longer useful? Buy-in by each stakeholder is essential. Before it can occur, each stakeholder needs to assure that the cocreated vision for the partnership remains true to each organization’s core mission. This is then followed by a series of agreements allocating the work to be done, specifying the project’s scope, as well as detailed responsibilities and expectations. Sometimes a memorandum of understanding describes only the work of the volunteer group or academic institution, omitting detailed responsibilities of each stakeholder and specific expected results. Compounding elements include linguistic barriers or nuances, unappreciated differences in cultural values, and political exigencies in the host country. It is essential that any contract, regardless of the form it takes, includes the nature of each party’s buy-in. Host country partners, for example, might define details about transportation, food, housing, translators, advertisements for the mission, promotion of educational meetings, assignment of a local project manager, and general preparedness. Open discussion of the above issues at the early stage of an alliance is akin to formulating a prenuptial agreement. The effort focuses on somewhat uncomfortable areas early on but begins the joint journey as impartially and transparently
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as possible. This “golden time” sets the stage for all that will transpire in the relationship. A secure, transparent foundation also sets a tone that will ensure successful adaptation to inevitable conflicts and unexpected challenges during the life of the contract. Just as important as entering a relationship is to either end it or recontract when it no longer serves the purposes it was created to achieve. Once a partnership is initiated, people often loathe to tackle the next essential step: evaluating in a dispassionate and transparent manner the various partners’ desires and needs against what is realistically achievable.
university partnerships emulate corporate models of organization in which evaluation of success is accredited by a board (which includes friendly associates or even the NGO leadership). In clinical research, by contrast, evaluation by an external IRB serves to challenge and question methods and outcomes. It has been suggested that such dispassionate review should also be available to global health aid groups. Decamp15 has expanded these research principles as they would apply to the ethics of STMMs.b
Accountability and Measuring Success-Early, Relevant, and Impartial
The various players involved in humanitarian aid may be viewed as “silos of excellence,” but it is in the “white spaces” between the silos where innovation can be sought.16 If transparent, active collaboration among NGOs and academic partnerships occurred, what improvements are possible? Results could include sharing “recipes for success;” avoiding the need for everyone to discover the same solutions independently; forging alliances to solve larger problems; preventing overlap and duplication; and amplifying the effectiveness of donor support. During the past decade, attention to the need for joint efforts has been growing, as evidenced by initiatives in the literature5,7,16,17 and conferences geared to discussing the challenges.c,18 A few nascent efforts have also shown promise.19 Evidence on the ground, however, suggests that most players continue in the main as solo actors, even if there is wider recognition that there is chaos when various organizations operate at cross purpose or trip over each other in their efforts to be helpful. Success and satisfaction will be derived not just from passion for volunteer aid missions but also from delving into the complexities of the existing state of medical humanitarian aid and creating new structures that address the multiple realities that influence and impact those efforts. It is imperative to acknowledge and understand the shortcomings of the current state and to continually strive to improve our individual and collective participation.
One NGO founder, communicating with an author of this article, stated: “We don’t need to measure anything. We know what we’re doing is good, and whatever outcomes we get are better than what they have without us.” Yet measuring and evaluating outcomes are intrinsic to improving any program. An essential early step in building a partnership is determining useful and relevant measures of success. An organization’s mission statement embodies the values by which its activities and results should be evaluated. Although an organization’s social humanitarian values are what attract donorsa, common outcome metrics frequently consist only of numerics: money spent on the mission; number of patients seen; number of conference attendees, etc. The humanitarian impacts—Were participants’ practices changed? How were lives improved by surgery? Did educational activities address the needs of attendees—are critical and more difficult to measure. Reporting hard data often leads to the tacit assumption that those numbers and raw outcomes are proxies for evaluating the core goal of humanitarian impact. Whether NGOs and academic organizations can impartially evaluate their work is open to question. Sustaining donor support and volunteer participants’ interest require ongoing reports of success. Host partners may fear losing a valuable relationship. Poor partner performance, duplicate efforts, serious medical complications, or poorly targeted training are frequently ignored or downplayed in favor of presenting agreeable metrics. An additional impediment to assuring quality is the fact that NGOs are not accountable to governments or outside entities for accreditation, quality, or efficiency.12 Yet improving NGOs performance has to involve establishing benchmarks and sharing experiences or finding common ground with similar groups for working in concert.
PUTTING IT ALL TOGETHER: RECOGNIZING INTER CONNECTEDNESS
BARRIERS TO SUCCESS-CHALLENGES TO WORKING COOPERATIVELY OR FORMING ALLIANCES
Although having NGOs and academic partnerships work jointly seems to offer many advantages, there are also obstacles that hinder them from working cooperatively or forming alliances: 1. Limited horizons. “We are just volunteers,” a persistent refrain indicating that engaging in a cause broader than the immediate mission feels either inappropriate or too demanding.
Ethical Issues
Ethical considerations for STMMs and voluntary partnerships share characteristics with clinical research.13,14 Principles include independent review of the proposal before it commences, collaborative partnering with the community, fairness in inclusion, benefit to the recipient population, and ongoing impartial evaluation. Most NGOs and a Bruderlein C, Dakkak M. Measuring Performance Versus Impact: Evaluation Practices and Their Implications on Governance and Accountability of Humanitarian Missions. Social Science Research Network. http://SSRN. com/abstract=149645. Accessed April 21, 2013
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Importantly, clinical research in LRC’s encompasses a broad range of unique collaborative and ethical challenges, a far-reaching topic beyond the scope of present discussion. (see: Akinremi TO. Research collaboration with low resource countries: Overcoming the challenges. Infect Agent Cancer 2011;6 (Suppl 2) S3).
b
examples: Emergency Capacity Building Project (http://www.ecbproject. org/the-project/theproject); Task force for Global Health (http://www. taskforce.org); CORE group (http://www.coregroup.org). Accessed April 21, 2013
c
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E SPECIAL ARTICLE Giving Back;e or the World Federation of Societies of Anesthesiologists f 2. Transparency for host entities. Efficient use of resources would be aided by in-country hosts indicating to potential partners their relationships with other academic partnerships, visiting providers, scholars, and STMMs. 3. Active donor involvement. Donors interested in optimizing outcomes need to set an expectation that NGOs investigate alliances with like-minded organizations and seek external review of projects. This would require major donors to recognize the value of synergizing resources. 4. Quality assurance. Surgical STMMs may improve outcomes and enhance their impact by participating in an appropriate quality assurance (QA) program. A pediatric-based program is Wake-up Safe, a cooperative QA project of the Society of Pediatric Anesthesiag. Internal QA processes may also be helpful in directing program improvements. 5. Benchmarks. Work with professional societies to develop common guidelines or benchmarks for safe practices to provide tools for outcome evaluation. 6. Validate measurements. Academic partnerships can work with professional societies and organizations having similar missions to develop validation methods for evaluating training programs. 7. Promote alliances and networks. Determine what forms and levels of alliance among NGOs will serve the best interests of the target community. Each stakeholder needs to seriously consider which type of alliance can favorably impact the human and monetary cost of their humanitarian efforts, as compared with working on one’s own.
2. Failure to identify all the stakeholders and complementary organizations.7 3. Fear of loss of mission. Multiagency cooperation may lead to a shift in focus, style, or control. 4. Lack of institutional memory. Turnover of key participants within organizations and host institutions and shifting political milieu preclude the continuity that characterizes strong networks. 5. Divisiveness and competition for favoritism within host institutions. 6. Threat of losing existing donor relationships. 7. Fear of adding costly and obstructive bureaucratic layers to a well-run organization. Time and energy resources invested in alliance building could become a greater priority than the core mission each group was originally created to tackle. 8. Self-perpetuation. Promoting the NGOs growth becomes a proxy for success.20 9. Paternalism sometimes masked as mutual respect. “Don’t worry we will bring it all.” Assuming in-country hosts to be weak partners serves to preclude mutual responsibility and buy-in.21 10. Reluctance to disclose organizational problems or medical complications. 11. Mistrust of other organizations’ competence (medical, organizational, and financial). 12. Being overwhelmed. Needs are so significant that diverting any time to alliance building seems unthinkable. 13. Inertia. (“Why Mess with Success?”) It requires far less effort to maintain the status quo than to engage in complex negotiations with additional partners. Benefits of engaging with other organizations may not be evident.
FROM CONCEPT TO REALITY
The purposes of education and service to indigent populations are well served when STMMs and academic organizations engage in mutual discussions; complement each other’s work; and seek frank, objective evaluation of their work and outcomes. Activities promoting these goals support innovative thinking, enhancing efficiency and minimizing waste and redundancy. The following steps are not easily undertaken, but they are fundamental to guiding organizations and their hosts in determining their degree of engagement in the partnership/collaboration continuum. 1. Transparency for NGOs. NGOs and academic institutions planning programs need to make sure they know what other groups are working in the arena. As a simple start, NGOs and academic institutions can publish their schedules for STMMs and their partnerships. NGOs deciding on a site and a date should directly ask their host who else will be at the site or in a nearby site in the same time period. Appropriate sites for surgical/anesthesia-based activities might include the website of the American Society of Anesthesiologists Global Humanitarian Outreachd; the American College of Surgeons’ Operation
SUMMARY
With growing activity in global health programs, a multitude of programs have been developed for training, building infrastructure, and services to indigent populations. Yet challenges remain in fractionation and duplication of efforts and development of objective evaluation of outcomes. We need to harness the passion of the many initiatives to create a more effective way to accomplish common goals. Collaboration does not just happen. It requires outreach, commitment, perseverance, trust, and transparency. Complex problems require complex expertise. Respectful harnessing of the potential of experts and novices promotes creative thinking, learning, and the formation of alliances. We need to challenge ourselves to devise ways to uncover the most powerful ideas to amplify our impact. E DISCLOSURES
Name: Quentin A. Fisher, MD. Contribution: This author participated in literature review, development of concepts, and preparation of this manuscript. Attestation: Quentin A. Fisher approved the final manuscript. http://www.operationgivingback.facs.org. Accessed April 21, 2013
e f
d
http://www.asahq.org/GHO/Contact-GHO.aspx. Accessed April 21, 2013
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http://www.anaesthesiologists.org. Accessed April 21, 2013
g
http://wakeupsafe.org. Accessed April 21,2013
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Name: Gail Fisher, MSW. Contribution: This author participated in literature review, development of concepts, and preparation of the manuscript. Attestation: Gail Fisher approved the final manuscript. This manuscript was handled by: Steven L. Shafer, MD. REFERENCES 1. Garfunkel LC, Howard CR. Expand education in global health: it is time. Acad Pediatr 2011;11:260–2 2. Anspacher M, Frintner MP, Denno D, Pak-Gorstein S, Olness K, Spector J, O’Callahan C. Global health education for pediatric residents: a national survey. Pediatrics 2011;128:e959–65 3. Ozgediz D, Roayaie K, Debas H, Schecter W, Farmer D. Surgery in developing countries: essential training in residency. Arch Surg 2005;140:795–800 4. Eneriz-Wiemer M, Nelson BD, Bruce J, Chamberlain LJ. Global health training in pediatric residency: a qualitative analysis of faculty director insights. Acad Pediatr 2012;12:238–44 5. Farmer P. Haiti After the Earthquake. New York, NY: Public Affairs, 2011 6. Crisp N. Global health capacity and workforce development: turning the world upside down. Infect Dis Clin North Am 2011;25:359–67 7. Rosenberg ML, Hayes ES. Real Collaboration: What It Takes for Global Health to Succeed. Berkeley, CA: University of California Press, 2010 8. Velji A, Bryant JH. Global health: evolving meanings. Infect Dis Clin North Am 2011;25:299–309 9. Polman L. The Crisis Caravan: What’s Wrong with Humanitarian Aid? New York, NY: Metropolitan Books-Henry Holt & Co., 2010
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10. Philpott J. Training for a global state of mind. Virtual Mentor 2010;12:231–6 11. Mattessich PW, Monsey BR. Collaboration: What Makes It Work, 2nd Edition: A Review of Research Literature on Factors Influencing Successful Collaboration. St. Paul, MN: Amherst H. Wilder Foundation, 1992 12. Frenk J, Moon S. Governance challenges in global health. N Engl J Med 2013;368:936–42 13. DeCamp M. Scrutinizing global short-term medical outreach. Hastings Cent Rep 2007;37:21–3 14. Philpott J. Applying themes from research ethics to international education partnerships. Virtual Mentor 2010;12:171–8 15. DeCamp M. Ethical review of global short-term medical volunteerism. HEC Forum 2011;23:91–103 16. Zolli A, Healy AM. Resilience: Why Things Bounce Back. New York, NY: Free Press, 2012 17. deVries CR, Price RR. Global Surgery and Public Health: a New Paradigm. Sudbury, MA: Jones & Bartlett Learning, 2012 18. Canadian Network for International Surgery. Bethune Round Table 2012 12th Annual Conference: Filling the Gap. Can J Surg. 2012;55:275–84 19. Lipnick M, Mijumbi C, Dubowitz G, Kaggwa S, Goetz L, Mabweijano J, Jayaraman S, Kwizera A, Tindimwebwa J, Ozgediz D. Surgery and anesthesia capacity-building in resource-poor settings: description of an ongoing academic partnership in Uganda. World J Surg 2013;37:488–97 20. Lupton R. Toxic Charity: How Churches and Charities Hurt Those They Help (And How to Reverse It). New York, NY: HarperOne, 2012 21. Moyo D. Dead Aid: Why Aid Is Not Working and How There Is a Better Way for Africa. New York, NY: Farrar, Straus and Giroux, 2009
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The Case for Collaboration Among Humanitarian Surgical Programs in Low Resource Countries Quentin A. Fisher, MD,* and Gail Fisher, MSW†
W
ith burgeoning activity in global health programs that provide training, medical-surgical services, and infrastructure support, participants become increasingly aware of the need for effective partnerships with like-minded and complementary organizations. Effective partnerships are critical in addressing the challenges of fractionation and duplication of efforts, development of meaningful conversations among agencies, and objective evaluation of value and outcome. Alliances are effective when the network of partners is chosen based on their unique contributions and capabilities, and members operate in a coordinated manner, amplifying one another’s capacities. A wide range of appropriate collaborative efforts are feasible for governmental agencies, nongovernmental organizations, academic institutions, and in-country hosts engaged in humanitarian surgical or educational assistance. Donors play an essential role in fostering communication and cooperation among agencies. In addition, transparency, ethical standards, quality review, and valid outcome measurement are universal components of effective humanitarian work.
SCENARIO 1
A short-term surgical mission on its third trip to a site in a low resource country (LRC) finds only a fraction of the expected number of patients arrive for screening. It is learned that another short-term surgical team targeting the same patients recently visited a different hospital in the same city.
SCENARIO 2
For many years, a group of visiting physicians have organized ad hoc teaching teams from their university to visit a LRC hospital at the invitation of a hospital department chair. They have always been warmly received by staff, and their efforts and donations appreciated. During 1 visit, the team encounters a similar group, only to learn both groups, to varying extent, had been replicating one another’s efforts.
SCENARIO 3
An organizational specialist was invited to a major hospital in a populous African capital city to assist on a project to coordinate nongovernmental organization (NGO) activities From the *Department of Anesthesiology, Georgetown University School of Medicine, Washington, DC; *Department of Anesthesiology, Medstar-Washington Hospital Center, Washington, DC; *Department of Anesthesiology, Uniformed Services University of the Health Sciences; and †Resources for Change, Bethesda, Maryland. Accepted for publication October 18, 2013. Funding: N/A. Dr. Quentin A. Fisher and Gail Fisher are cofirst authors. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Quentin A. Fisher, MD, Department of Anesthesiology, Medstar-Washington Hospital Center, 110 Irving St., NW, Washington DC 20010. Address e-mail to [email protected]. Copyright © 2014 International Anesthesia Research Society DOI: 10.1213/ANE.0000000000000053
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from a variety of donor countries. For years, NGOs, visiting scholars, and international agencies had been helping to fill gaps in services, training, and equipment. Hospital staff was sincerely grateful for much of the help but felt the “deluge” was often overwhelming, and that they were displaced in their operating rooms, judged by their sponsors, and saddled with cast-off materials. The hospital director was seeking to coordinate the varied aid programs to better direct the largesse toward what staff knew to be their needs. However, the hospital’s many department chairs had their own arrangements with a variety of outside supporters and researchers, and there was no effective overall oversight or coordination. Some department chairs were reluctant to identify their contacts, fearing they could risk loss of many material and professional benefits.
STATE OF THE ART
In recent years, there has been increased interest and rapid expansion in global health activity by universities, residency training programs, and NGOs.1 Surveys2,3 have found that opportunities for experience in LRCs are attractive to residency applicants in a variety of specialties. Similarly, there has been substantially broadened activity by NGOs engaged in both short-term medical missions (STMMs) and educational support programs. While much is being accomplished in providing services and educational experiences, the growth in global outreach has also been accompanied by demonstrable duplication of services, inefficient use of human and monetary resources, diversion of assets, and imposition of stresses on host institutions.4,5 Many of these drawbacks are tolerated as the cost of doing business in austere settings. Whether the primary goal is to provide care to indigent patients or educate local medical staff, voluntary medical programs invest enormously in planning, logistics, funding, and personnel to assure successful missions. Far lower priority is given to broader nonclinical issues that may impact long-term effectiveness, efficiency, and sustainability. Developing authentic working relationships with complementary and like-minded organizations leads to tackling a broad range of concerns such as mounting surgical missions too close to one another in time or locale; creating overlapping university partnerships within the same hospital and department; or unknowingly, allying with previously unsuccessful in-country partners. With more frequent and sustained international contacts, some LRC hosts have broadened their expectations of what is desirable and possible. Ministries of health may depend on NGOs to fill their infrastructure gaps.6 As the number and frequency of NGO visits to a site increases, so does the complexity for the hosts to effectively utilize those resources, know what to appropriately ask of NGOs, and plan for disruptions to the hospital routine. Adding to the challenge is the fact that multiple in-country hosts may have relationships with NGOs from many different countries. February 2014 • Volume 118 • Number 2
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The overall challenge, in essence, is to seek ways in which in-country hosts can identify their needs, and with their stakeholders cocreate actionable solutions to meet them. Working relationships with host country hospital hierarchy and government officials are not governed by the size or type of NGO. It is as likely that leaders of small groups have good or nonexistent relationships with government ministers and hospital directors as their larger counterparts. Solutions entail going beyond the current paradigm to include the expertise of a spectrum of interests, including the hosts and complementary agencies.7 The following sections examine how effective achievement of stated goals by STMMs and academic partnerships can be positively impacted by considering the larger contexts of NGO activities. Such contexts include: (1) effective partnerships between volunteer agencies and in-country hosts; (2) alliances with complementary and like-minded organizations and in-country authorities; and (3) ethical dimensions in sending teams abroad.
Evolutionary Maturation of Short-Term Surgical Programs
While individuals and small groups have been providing surgical care in STMMs for a long time, the development of larger international surgical programs is mostly a product of the past 2 to 3 decades.8 Initially, the catalysts for many programs were recognition of a need, personal professional contacts, and a vision for addressing a need on a small scale. Over time, many of these small programs evolved into sophisticated, internationally based, and respected NGOs. Still other programs developed as “spin-offs” organized by individuals from large NGOs (“my own NGO” or MONGO).9 Yet, even large, mature organizations may lack professional managers; instead, they rely on physicians with varying degrees of business or organizational expertise or on-the-job learning. At present, STMMs, NGOs, and academic partnerships may be found operating at various points of the spectrum, from small groups using local equipment and supplies requiring considerable improvisation to larger groups with formal administrative infrastructure that are entirely self-funded and able to attract well-qualified specialists for their teams.
GOOD INTENTIONS-HOW IS IT THAT...?
As exemplified by the 3 scenarios above, well-intentioned volunteer groups may find themselves confronting various conundrums as they perform their projects. Competing interests by stakeholders (Table 1) may well lead to problems such as: • sites chosen based solely on personal relationships; • assertive solicitations for aid by host country providers; • sites selected due to greater availability of infrastructure (e.g., hospital beds, operating rooms, services for volunteers, and easy transportation); • donor preference; or conversely, lack of programmatic direction by donor; • failure to clearly articulate goals and expectations or to align them with what is realistic. An issue that has wide-ranging ramifications, but one beyond the scope of this paper, is the role of “personal stake/pride.” Philpott10 examined the significance of gaining status by being a mission volunteer; many host country colleagues also speak freely of the professional stature they have attained by attracting institutions and equipment donations to their facilities. Nonparticipating physicians in host countries may feel undermined by the implied message that they cannot care for their own patients since patients often voice their preference for a foreign doctor.
DEVELOPING SUCCESSFUL, INNOVATIVE NETWORKS AND ALLIANCES
The processes to build networks and collaborations that will strengthen missions and lead to creative innovations must occur both within an organization and among organizations. The basics of developing a successful, high-impact humanitarian program of any size mirror how successful humanitarian programs network to strengthen partnerships among themselves. The principles that apply to “my own NGOs” are also salient for large multinational NGOs. Most important, the success of international alliances hinges on organizations’ strategic objectives and the choice of appropriate partner(s) to meet them. Organizations must look beyond their own capacities and involve others (e.g., NGOs, government agencies, and private sector organizations) whose strengths enhance and synergize their own.
Donors Drive Mission Work
Donors are the engines of voluntary humanitarian work. They include individual and small-group contributors, NGO board members, expatriates, industry sponsors, and government agencies. Donors are concerned about the overall mission, financial efficiency, measured outcomes, and competition from like-minded groups. But in many instances, the donor’s role is largely restricted to funding their chosen mission. When major donors also sit on STMM boards, objective and dispassionate program evaluations are unlikely. With the possible exception of some large donors supporting multinational projects, donors to surgical STMMs have not played a substantive role in inviting NGOs to discuss common goals and challenges. Thus, despite their critical function in promoting the NGOs, donors actually have had little part in directing programs or requiring cooperation among groups.
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Table 1. Stakeholders in Surgical Short-Term Medical Missions Nongovernmental organization (NGO) NGO board of directors NGO leadership Clinical directors NGO employees Volunteers Donors National expatriates Government agencies (may compete for resources) Colleagues who cover the absent volunteer’s duties
Host country Hospital director In-country contact hosts and liaisons Participating professionals Patients and families Nonparticipating medical community Government agencies (e.g. Minister of health, customs) Medical universities National professional societies
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E SPECIAL ARTICLE The process of identifying potential partners is multidimensional. It is characterized by: clearly articulating mutual goals; building strong relationships; contracting for specific areas of responsibility and accountability; and measuring both clinical and organizational outcomes.
uniqueness and differences; listening intently; demonstrating respect; viewing well-managed conflict as productive; honestly acknowledging mistakes and weaknesses; being open to feedback; and being prepared to act on mutually accepted changes.
Partner Selection (Both NGO and In-Country Host)
Contracting: A Successful Beginning Starts with the End
“In developing countries, because of their situation they are more willing to say, ‘yes come on in, we want your help,’ but they may be passive. Without their active involvement and commitment of the host country, the effort is likely to fail.” Seth Berkley, President, International Aids Vaccine Initiative7 Projects exist as partnerships involving individuals, informally organized groups of colleagues, NGOs, hospitals, and academic programs in a variety of combinations. The success of international partnerships requires alignment of the strategic objectives among the NGOs and the in-country interests for the venture. Evaluating the potential for partnership requires mutual consideration of: • mission alignment; • diversity of skills to achieve successful mission outcomes; • partner compatibility based both on demonstrable mutual respect and willingness to align personal agendas in a transparent manner with those of the partnership; • decision-making authority available to all stakeholders; • influence with and access to resources (including stakeholders, government agencies, and community activists).
Relationship Building-an Intentional Effort Toward Meaningful Outcomes
Authentic people-to-people interest, concern, and caring set the stage for all the hard work to follow. Individuals who volunteer frequently excel at all 3. They know the value of good working relationships based on trust, mutuality, and respect. They recognize that it takes time to appreciate the varying skill sets of each team member and to understand how best to work together. Relationship building with the in-country hosts can be no less challenging, even when the NGO is on site by invitation. Successful partnerships acknowledge there are complexities experienced by all parties. In-country providers deal routinely with trying circumstances that demand ingenuity, discipline, and not infrequently, courage. Organizations must be aware of, and avoid, imposing interventions on host communities. At the same time, hosts’ best interests are served by understanding the time constraints of the volunteer organizations and by being conscientious in following through on mutually agreed commitments. Stakeholders can engage most effectively if all involved are aware of, and sensitive to, the antecedent efforts of a proposed project. Equally important is to have an awareness of parallel efforts by other providers. Both within organizations and among network alliances, the characteristics of healthy partnerships include: valuing
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An objection frequently voiced in the humanitarian field is: “We are only volunteers. We don’t want to duplicate the bureaucracy and paperwork we have to deal with back home. We simply want to come in and do a good job.” With understandable eagerness to launch a valuable project, a quickly conceptualized memorandum of understanding may take the place of thoughtful attention to cocreating durable fundamentals. As a result, the need for partnerships to clearly articulate what they hope to achieve, and what their expectations are for each partner may have been left as a tacit understanding. These can lead to mission drift or even untimely dissolution of the relationship. Partnerships that devote attention to strategy, organization, and capability development at the outset, revisiting these periodically, are more successful in their collaboration efforts.11 Robust partnerships develop a clear vision and plan, by discussing the following: • What would success in our work together look like? • How will we measure success? • What are our mutual expectations and responsibilities? • How do we demonstrate buy-in to one another? • How will we specifically help each other? • What will be the timeline for incremental steps toward our goal? • How will we know when our work is done? • How will we know if the current form of our partnership is no longer useful? Buy-in by each stakeholder is essential. Before it can occur, each stakeholder needs to assure that the cocreated vision for the partnership remains true to each organization’s core mission. This is then followed by a series of agreements allocating the work to be done, specifying the project’s scope, as well as detailed responsibilities and expectations. Sometimes a memorandum of understanding describes only the work of the volunteer group or academic institution, omitting detailed responsibilities of each stakeholder and specific expected results. Compounding elements include linguistic barriers or nuances, unappreciated differences in cultural values, and political exigencies in the host country. It is essential that any contract, regardless of the form it takes, includes the nature of each party’s buy-in. Host country partners, for example, might define details about transportation, food, housing, translators, advertisements for the mission, promotion of educational meetings, assignment of a local project manager, and general preparedness. Open discussion of the above issues at the early stage of an alliance is akin to formulating a prenuptial agreement. The effort focuses on somewhat uncomfortable areas early on but begins the joint journey as impartially and transparently
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as possible. This “golden time” sets the stage for all that will transpire in the relationship. A secure, transparent foundation also sets a tone that will ensure successful adaptation to inevitable conflicts and unexpected challenges during the life of the contract. Just as important as entering a relationship is to either end it or recontract when it no longer serves the purposes it was created to achieve. Once a partnership is initiated, people often loathe to tackle the next essential step: evaluating in a dispassionate and transparent manner the various partners’ desires and needs against what is realistically achievable.
university partnerships emulate corporate models of organization in which evaluation of success is accredited by a board (which includes friendly associates or even the NGO leadership). In clinical research, by contrast, evaluation by an external IRB serves to challenge and question methods and outcomes. It has been suggested that such dispassionate review should also be available to global health aid groups. Decamp15 has expanded these research principles as they would apply to the ethics of STMMs.b
Accountability and Measuring Success-Early, Relevant, and Impartial
The various players involved in humanitarian aid may be viewed as “silos of excellence,” but it is in the “white spaces” between the silos where innovation can be sought.16 If transparent, active collaboration among NGOs and academic partnerships occurred, what improvements are possible? Results could include sharing “recipes for success;” avoiding the need for everyone to discover the same solutions independently; forging alliances to solve larger problems; preventing overlap and duplication; and amplifying the effectiveness of donor support. During the past decade, attention to the need for joint efforts has been growing, as evidenced by initiatives in the literature5,7,16,17 and conferences geared to discussing the challenges.c,18 A few nascent efforts have also shown promise.19 Evidence on the ground, however, suggests that most players continue in the main as solo actors, even if there is wider recognition that there is chaos when various organizations operate at cross purpose or trip over each other in their efforts to be helpful. Success and satisfaction will be derived not just from passion for volunteer aid missions but also from delving into the complexities of the existing state of medical humanitarian aid and creating new structures that address the multiple realities that influence and impact those efforts. It is imperative to acknowledge and understand the shortcomings of the current state and to continually strive to improve our individual and collective participation.
One NGO founder, communicating with an author of this article, stated: “We don’t need to measure anything. We know what we’re doing is good, and whatever outcomes we get are better than what they have without us.” Yet measuring and evaluating outcomes are intrinsic to improving any program. An essential early step in building a partnership is determining useful and relevant measures of success. An organization’s mission statement embodies the values by which its activities and results should be evaluated. Although an organization’s social humanitarian values are what attract donorsa, common outcome metrics frequently consist only of numerics: money spent on the mission; number of patients seen; number of conference attendees, etc. The humanitarian impacts—Were participants’ practices changed? How were lives improved by surgery? Did educational activities address the needs of attendees—are critical and more difficult to measure. Reporting hard data often leads to the tacit assumption that those numbers and raw outcomes are proxies for evaluating the core goal of humanitarian impact. Whether NGOs and academic organizations can impartially evaluate their work is open to question. Sustaining donor support and volunteer participants’ interest require ongoing reports of success. Host partners may fear losing a valuable relationship. Poor partner performance, duplicate efforts, serious medical complications, or poorly targeted training are frequently ignored or downplayed in favor of presenting agreeable metrics. An additional impediment to assuring quality is the fact that NGOs are not accountable to governments or outside entities for accreditation, quality, or efficiency.12 Yet improving NGOs performance has to involve establishing benchmarks and sharing experiences or finding common ground with similar groups for working in concert.
PUTTING IT ALL TOGETHER: RECOGNIZING INTER CONNECTEDNESS
BARRIERS TO SUCCESS-CHALLENGES TO WORKING COOPERATIVELY OR FORMING ALLIANCES
Although having NGOs and academic partnerships work jointly seems to offer many advantages, there are also obstacles that hinder them from working cooperatively or forming alliances: 1. Limited horizons. “We are just volunteers,” a persistent refrain indicating that engaging in a cause broader than the immediate mission feels either inappropriate or too demanding.
Ethical Issues
Ethical considerations for STMMs and voluntary partnerships share characteristics with clinical research.13,14 Principles include independent review of the proposal before it commences, collaborative partnering with the community, fairness in inclusion, benefit to the recipient population, and ongoing impartial evaluation. Most NGOs and a Bruderlein C, Dakkak M. Measuring Performance Versus Impact: Evaluation Practices and Their Implications on Governance and Accountability of Humanitarian Missions. Social Science Research Network. http://SSRN. com/abstract=149645. Accessed April 21, 2013
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Importantly, clinical research in LRC’s encompasses a broad range of unique collaborative and ethical challenges, a far-reaching topic beyond the scope of present discussion. (see: Akinremi TO. Research collaboration with low resource countries: Overcoming the challenges. Infect Agent Cancer 2011;6 (Suppl 2) S3).
b
examples: Emergency Capacity Building Project (http://www.ecbproject. org/the-project/theproject); Task force for Global Health (http://www. taskforce.org); CORE group (http://www.coregroup.org). Accessed April 21, 2013
c
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E SPECIAL ARTICLE Giving Back;e or the World Federation of Societies of Anesthesiologists f 2. Transparency for host entities. Efficient use of resources would be aided by in-country hosts indicating to potential partners their relationships with other academic partnerships, visiting providers, scholars, and STMMs. 3. Active donor involvement. Donors interested in optimizing outcomes need to set an expectation that NGOs investigate alliances with like-minded organizations and seek external review of projects. This would require major donors to recognize the value of synergizing resources. 4. Quality assurance. Surgical STMMs may improve outcomes and enhance their impact by participating in an appropriate quality assurance (QA) program. A pediatric-based program is Wake-up Safe, a cooperative QA project of the Society of Pediatric Anesthesiag. Internal QA processes may also be helpful in directing program improvements. 5. Benchmarks. Work with professional societies to develop common guidelines or benchmarks for safe practices to provide tools for outcome evaluation. 6. Validate measurements. Academic partnerships can work with professional societies and organizations having similar missions to develop validation methods for evaluating training programs. 7. Promote alliances and networks. Determine what forms and levels of alliance among NGOs will serve the best interests of the target community. Each stakeholder needs to seriously consider which type of alliance can favorably impact the human and monetary cost of their humanitarian efforts, as compared with working on one’s own.
2. Failure to identify all the stakeholders and complementary organizations.7 3. Fear of loss of mission. Multiagency cooperation may lead to a shift in focus, style, or control. 4. Lack of institutional memory. Turnover of key participants within organizations and host institutions and shifting political milieu preclude the continuity that characterizes strong networks. 5. Divisiveness and competition for favoritism within host institutions. 6. Threat of losing existing donor relationships. 7. Fear of adding costly and obstructive bureaucratic layers to a well-run organization. Time and energy resources invested in alliance building could become a greater priority than the core mission each group was originally created to tackle. 8. Self-perpetuation. Promoting the NGOs growth becomes a proxy for success.20 9. Paternalism sometimes masked as mutual respect. “Don’t worry we will bring it all.” Assuming in-country hosts to be weak partners serves to preclude mutual responsibility and buy-in.21 10. Reluctance to disclose organizational problems or medical complications. 11. Mistrust of other organizations’ competence (medical, organizational, and financial). 12. Being overwhelmed. Needs are so significant that diverting any time to alliance building seems unthinkable. 13. Inertia. (“Why Mess with Success?”) It requires far less effort to maintain the status quo than to engage in complex negotiations with additional partners. Benefits of engaging with other organizations may not be evident.
FROM CONCEPT TO REALITY
The purposes of education and service to indigent populations are well served when STMMs and academic organizations engage in mutual discussions; complement each other’s work; and seek frank, objective evaluation of their work and outcomes. Activities promoting these goals support innovative thinking, enhancing efficiency and minimizing waste and redundancy. The following steps are not easily undertaken, but they are fundamental to guiding organizations and their hosts in determining their degree of engagement in the partnership/collaboration continuum. 1. Transparency for NGOs. NGOs and academic institutions planning programs need to make sure they know what other groups are working in the arena. As a simple start, NGOs and academic institutions can publish their schedules for STMMs and their partnerships. NGOs deciding on a site and a date should directly ask their host who else will be at the site or in a nearby site in the same time period. Appropriate sites for surgical/anesthesia-based activities might include the website of the American Society of Anesthesiologists Global Humanitarian Outreachd; the American College of Surgeons’ Operation
SUMMARY
With growing activity in global health programs, a multitude of programs have been developed for training, building infrastructure, and services to indigent populations. Yet challenges remain in fractionation and duplication of efforts and development of objective evaluation of outcomes. We need to harness the passion of the many initiatives to create a more effective way to accomplish common goals. Collaboration does not just happen. It requires outreach, commitment, perseverance, trust, and transparency. Complex problems require complex expertise. Respectful harnessing of the potential of experts and novices promotes creative thinking, learning, and the formation of alliances. We need to challenge ourselves to devise ways to uncover the most powerful ideas to amplify our impact. E DISCLOSURES
Name: Quentin A. Fisher, MD. Contribution: This author participated in literature review, development of concepts, and preparation of this manuscript. Attestation: Quentin A. Fisher approved the final manuscript. http://www.operationgivingback.facs.org. Accessed April 21, 2013
e f
d
http://www.asahq.org/GHO/Contact-GHO.aspx. Accessed April 21, 2013
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http://www.anaesthesiologists.org. Accessed April 21, 2013
g
http://wakeupsafe.org. Accessed April 21,2013
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Name: Gail Fisher, MSW. Contribution: This author participated in literature review, development of concepts, and preparation of the manuscript. Attestation: Gail Fisher approved the final manuscript. This manuscript was handled by: Steven L. Shafer, MD. REFERENCES 1. Garfunkel LC, Howard CR. Expand education in global health: it is time. Acad Pediatr 2011;11:260–2 2. Anspacher M, Frintner MP, Denno D, Pak-Gorstein S, Olness K, Spector J, O’Callahan C. Global health education for pediatric residents: a national survey. Pediatrics 2011;128:e959–65 3. Ozgediz D, Roayaie K, Debas H, Schecter W, Farmer D. Surgery in developing countries: essential training in residency. Arch Surg 2005;140:795–800 4. Eneriz-Wiemer M, Nelson BD, Bruce J, Chamberlain LJ. Global health training in pediatric residency: a qualitative analysis of faculty director insights. Acad Pediatr 2012;12:238–44 5. Farmer P. Haiti After the Earthquake. New York, NY: Public Affairs, 2011 6. Crisp N. Global health capacity and workforce development: turning the world upside down. Infect Dis Clin North Am 2011;25:359–67 7. Rosenberg ML, Hayes ES. Real Collaboration: What It Takes for Global Health to Succeed. Berkeley, CA: University of California Press, 2010 8. Velji A, Bryant JH. Global health: evolving meanings. Infect Dis Clin North Am 2011;25:299–309 9. Polman L. The Crisis Caravan: What’s Wrong with Humanitarian Aid? New York, NY: Metropolitan Books-Henry Holt & Co., 2010
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10. Philpott J. Training for a global state of mind. Virtual Mentor 2010;12:231–6 11. Mattessich PW, Monsey BR. Collaboration: What Makes It Work, 2nd Edition: A Review of Research Literature on Factors Influencing Successful Collaboration. St. Paul, MN: Amherst H. Wilder Foundation, 1992 12. Frenk J, Moon S. Governance challenges in global health. N Engl J Med 2013;368:936–42 13. DeCamp M. Scrutinizing global short-term medical outreach. Hastings Cent Rep 2007;37:21–3 14. Philpott J. Applying themes from research ethics to international education partnerships. Virtual Mentor 2010;12:171–8 15. DeCamp M. Ethical review of global short-term medical volunteerism. HEC Forum 2011;23:91–103 16. Zolli A, Healy AM. Resilience: Why Things Bounce Back. New York, NY: Free Press, 2012 17. deVries CR, Price RR. Global Surgery and Public Health: a New Paradigm. Sudbury, MA: Jones & Bartlett Learning, 2012 18. Canadian Network for International Surgery. Bethune Round Table 2012 12th Annual Conference: Filling the Gap. Can J Surg. 2012;55:275–84 19. Lipnick M, Mijumbi C, Dubowitz G, Kaggwa S, Goetz L, Mabweijano J, Jayaraman S, Kwizera A, Tindimwebwa J, Ozgediz D. Surgery and anesthesia capacity-building in resource-poor settings: description of an ongoing academic partnership in Uganda. World J Surg 2013;37:488–97 20. Lupton R. Toxic Charity: How Churches and Charities Hurt Those They Help (And How to Reverse It). New York, NY: HarperOne, 2012 21. Moyo D. Dead Aid: Why Aid Is Not Working and How There Is a Better Way for Africa. New York, NY: Farrar, Straus and Giroux, 2009
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