Healthcare Needs of Guatemalan Communities
When informants were questioned about what they believed to be the most pressing healthcare needs in Guatemala, a number of public health measures invariably topped the list. The most commonly cited healthcare needs included improved efforts at disease prevention through health education and disease screening programs; improved public health infrastructure; and improved access to primary medical care, particularly in Guatemala's rural areas.
A number of informants focused on poverty as the key determinant of the health disparities between the people of wealthy and poor countries. One Guatemalan surgeon working at a large national hospital stated the problem in the following way:
[Foreign] surgical teams only work on the tip of the iceberg when it comes to addressing the medical problems of this country. The problems of Guatemala – corruption, lack of resources, lack of education – all come from poverty. So poverty is the root of the problem, and surgery does not address poverty.
When the question of healthcare needs in Guatemala was posed to a high-ranking official at the Ministry of Health (MSPAS), he emphasized that the "primary problem in Guatemala is a lack of public health infrastructure and lack of primary care coverage due to a lack of financial resources," further explaining that:
[Short-term medical work] does not, and cannot, address these primary health issues of Guatemala. We already have many surgeons and other physicians who are well trained to take care of all problems common in our country. The lack of healthcare in rural areas is not due to a lack of physicians; it is due to a lack of resources to provide clinics, hospitals, and supplies to these areas.
While none of our informants suggested that short-term volunteer medical work could solve the country's most pressing healthcare needs, there was nevertheless unanimous acknowledgement of the need for increased access to curative medical care, especially for the poorest populations in Guatemala. Informants cited the public healthcare system (MSPAS system), as tending to be the most accessible option to low-income populations in Guatemala. However, a Guatemalan primary care physician working in a foreign-funded hospital explained the pitfalls in the Guatemalan healthcare system:
Even though the national hospitals do not charge anything for their services, preoperative studies are frequently needed for scheduled surgeries. If the national hospital does not have the equipment to do the studies, the patient must go to other places to get them and at times has to pay a lot of money. So even though the national hospital provides health services for free, the patient frequently encounters costs that can prevent a poor patient from receiving necessary treatment.
In addition, given the high levels of poverty discussed above, simply traveling to a healthcare facility can be financially burdensome for a significant portion of the Guatemalan population. Compounding this problem is the paucity of specialists outside of Guatemala City and other larger cities. A physician who is an official at the College of Physicians and Surgeons, stated that "Eighty percent of Guatemala's specialists live and work in Guatemala City, so there is a vast shortage of specialists elsewhere." In explaining the reasons for the lack of Guatemalan specialists working in poor, rural areas, one official at MSPAS stated that:
Physicians working within the public healthcare system are underpaid...the financial incentives to work in a poor area do not exist. All of the specialists end up living in big cities, sometimes splitting their work between public and private practice.
In addition to the economic and geographic barriers to accessing healthcare, language and discrimination were also noted as significant impediments to care. One informant is a Guatemalan employee of a US-funded NGO that works closely with local community leaders in rural villages to seek out patients who are in need of surgery. This organization then coordinates the surgery, linking patients with visiting surgical teams. If needed, they also facilitate and help to pay for the transportation, translators (if the patients do not speak Spanish), accommodations, and food for the patient. This informant reflected that many of the indigenous people (who tend to be those who live in the most rural, poverty stricken areas) are afraid to have surgery and often only speak an indigenous language rather than Spanish, which prevents these patients from entering into Guatemala's public healthcare system. An indigenous Guatemalan whose son was being aided by this US NGO had traveled 8 hours by bus with her son who was awaiting hand surgery from a US short-term surgical team. She stated that she felt physicians at the national hospitals helped those with money first, and then, if there is time, they would see the poor last.
Dependence on Foreign Providers
Over the course of our interviews, the issue of dependence was frequently raised by both Guatemalans and foreigners. One repeatedly cited criticism was that foreign medical projects remove or lessen the incentive for the government to invest in healthcare for their own people. A Guatemalan physician who works in a foreign-funded hospital which is currently the only hospital in the area offering 24-hour emergency and surgical/obstetrical care is, along with a number of other physicians in the area, petitioning the government to build a full-service, government-run health center in his area. He explained that in deciding where to invest money in improving healthcare services, the government "only considers the number of existing healthcare services already in the area, regardless of the quality of services provided." Thus, the presence of multiple NGO health projects in the area may actually impede development of the area's public healthcare infrastructure.
In addition to the potential for governmental dependence on foreign medical aid, many informants described the problem of patient reliance on free medical and/or surgical care provided by short-term volunteers. A Guatemalan administrator working in a local NGO which provides reproductive health services throughout Guatemala, expressed her concerns regarding free care provided by foreign medical groups:
Patients get used to the free care and end up waiting for the next group to arrive to give them free care rather than seeking out ways in which they can help themselves. What will happen when all the NGOs leave? The people won't know how to go about finding a way to get care.
Similar sentiments were noted by an American surgeon and head of an NGO in Guatemala, who stated, "If a volunteer group provides free healthcare, the community can become spoiled and end up relying on that service rather than on the permanent [government-run] system which already exists."
Patient Selection and Payment Systems
When our informants were questioned about ways in which dependence on foreign aid could potentially be avoided, appropriate patient selection and attention to the payment system were most frequently mentioned. When discussing the issue of patient selection, there was almost universal agreement between both Guatemalans and foreigners that short-term volunteer groups should focus their services on the populations who are most in-need. The most frequently cited challenge to shot-term medical volunteer work was the task of reaching the patients who truly cannot afford other options for medical attention. We spoke with a Guatemalan physician working in a clinic that was hosting a North American short-term surgical group. He expressed his concern that the aid provided by volunteers may not actually be reaching the poorest people in Guatemala and emphasized that if patients who can afford to pay for their own private care receive free care from foreign volunteer groups, those volunteer groups end up competing with the private Guatemalan physicians (who could perform the same surgeries, but for a fee) for patients. He went on to describe the challenge of trying to suggest to the North American group that they perform a financial evaluation of all patients in order to help target those who truly cannot afford to pay for surgery. He stated that he sensed that the North Americans "seem to perceive everyone in Guatemala to be poor, and therefore do not think it is important to do a socioeconomic evaluation."
Informants' opinions on which payment system should be used by short-term medical groups were varied. One head coordinator of a short-term medical volunteer group stated that their group provided "completely free surgical care to every patient without an evaluation of their ability to pay." A number of informants criticized this form of care, suggesting that it becomes "detrimental to society" by causing disinvestment in healthcare by the government to take care of their own population, dependence on outside aid, and competition with the existing healthcare system.
A few informants were of the opinion that short-term medical volunteer work should be free to those patients who cannot afford care in Guatemala. One foreign-born surgeon, who has been operating full-time in poor countries for nearly 20 years, stated that he provides completely free surgery to the "poorest of the poor" through a private foundation. He described why he chooses to do this in the following way:
Last year, I did over 5000 free surgeries for the poor around the world and if my patients would have had to pay for this care, I probably would have done half that number of surgeries. The poorest patients do not have the resources even to be able to afford the transportation, accommodation and food while they are in the hospital, let alone the surgical and medical care...What's the definition of charity if it's not free?
In addition, two out of the four health promoters working in rural, poverty-stricken areas described the free care provided by short-term medical volunteers as one of the greatest benefits to their patients. One health promoter stated, "If [patients] have to pay for their care, some are so poor that they will have to choose between paying for food and paying for their medical care."
Of the 20 informants who discussed the issue of payment directly, fourteen believed that all patients should pay something for their treatment. Most believed that when patients were asked to pay for their treatment, they were in a better position to feel as though they had ownership of their own care, rather than being passive informants in that care. A leader of a US NGO that seeks out patients in rural areas in need of surgical care always has the patient pay something for this service (often it is only a few quetzals – equivalent to less than $1 USD). He described his reasoning in the following way:
I remember talking to a couple of patients who came back from a free surgical [short-term medical volunteer group] who were dissatisfied with their care. When pressed for why they were dissatisfied, they said the facility made them clean up their own area, or they didn't have tortillas – small, irrelevant reasons for their dissatisfaction with their care. I have never had that experience with patients who have to pay something for their care.
Another administrator at a Guatemalan NGO echoed these sentiments by saying, "Even the poorest people in the country can find five quetzals. The point isn't to cover the cost of the care. Rather, the point is to get people to take more responsibility for their own care."
Nearly all of the informants who believed in asking for payment from patients (including Guatemalan healthcare providers, health authorities, community members, and foreigners) suggested using a sliding scale system of payment, in which the amount patients are asked to pay is based on a careful socioeconomic screen performed by social workers and/or leaders of the patient's community, who are in the best position to know what the patient can actually afford to pay. Again, the informants emphasized that the payments should never jeopardize the patients' ability to obtain health care.
Burden on Host Organization/Community
Another major theme frequently discussed by the informants was that short-term medical volunteers have the potential to be quite burdensome (both financially and in terms of personnel time) for host organizations and communities in Guatemala. It should be noted that nearly every Guatemalan interviewee expressed appreciation for the service that visiting teams provided to their communities and many acknowledged the personal sacrifices that individual volunteers made in order to provide these services. Nevertheless, there was also a great deal of discussion about how this type of work can become financially burdensome for the host organization. One Guatemalan project coordinator of short-term medical volunteers expressed that he felt he was "half project coordinator and half tour guide. I have to arrange transportation, accommodation, food, and translators for all of the volunteers."
Many informants noted that a big disadvantage to short-term medical volunteer work is the strain on local personnel time when the volunteers did not know the language or were unfamiliar with the clinic setting. A project coordinator of a US NGO stated that, "When the volunteer doesn't speak the language, misunderstandings can occur and cause big problems, not only for patients, but also for local staff who work with the volunteers."
Some short-term medical volunteer organizations have tried to combat this problem by asking their volunteers to pay for their own expenses. The head of an NGO which regularly organizes surgical short-term medical volunteer work in a private hospital in Guatemala, expressed the following thoughts:
We get into trouble when physicians just bring their hands. We ask all of our volunteers to cover their own expenses, such as travel, lodging, and food. We also cover the cost of each surgery, including supplies and electricity in the operating rooms, and to offset the financial burden on the hospital of providing follow-up care, our visiting groups make a donation to the hospital for each patient they operate on. We understand that it is very expensive for any facility to host short-term volunteers.
Numerous informants suggested that it is best to limit the number of people on a visiting medical team to only those who are necessary, as large groups tend to get in the way of the regular operations at host facilities and end up being a rather large burden. As an extreme example, a physician who has worked on various medical aid projects around the world, told us of a visiting medical team from the US which brought 78 people, including surgeons, primary care physicians, nurses, cooks and translators. He continued:
Guatemala already has doctors, nurses, cooks and translators. So, it would be better to bring the specialists that may be needed and then utilize as many in-country personnel as possible to carry out the mission. In that way, you are wasting less money, strengthening the country's healthcare resources, helping the country's economy, and increasing the quality of care.
Many Guatemalan informants talked about a level of arrogance or elitism that they often see in visiting medical professionals. Most of these informants noted that when foreign providers work in coordination with the local healthcare providers, it reflects an acknowledgement that the local providers are competent. Working in isolation from the surrounding medical community was perceived to reflect the opposite sentiment. Furthermore, the respect shown to local providers by working alongside them is also perceived to be visible by the local patient population, which has a positive impact on the local provider's relationship with their community.
Some Guatemalan physicians described their frustration with visiting medical teams who work in isolation from the local medical community. A Guatemalan surgeon who works in a private clinic as well as a national hospital poignantly stated:
Guatemalan patients, especially those with less education, tend to put more faith in a blonde haired, blue eyed, white skinned foreign physician than their own Guatemalan physicians. These foreigners show up with their shiny new equipment and do their free surgeries without ever working with any of [the Guatemalan physicians]. US doctors come to Guatemala and practice medicine when and where they want. Guatemalan doctors may have a hard time even entering the US, let alone being able to practice medicine there. US physicians are not superior to Guatemalans. I am perfectly capable of taking care of my own people.
In discussing the utility of short-term medical volunteer work with the co-founder of a successful NGO that organizes US surgical teams to perform surgeries in Guatemala, he said, "Short-term volunteer work can be completely effective if it's attached to a long-term program." The importance of short-term medical volunteers coordinating their activities with groups that have a long-term presence in Guatemala was by far the most frequent recommendation made by our informants. In fact, it was often more of a demand than a recommendation, with some informants commenting that short-term medical volunteer work that is not coordinated with a long-term presence is "the worst kind of care," or that those short-term medical volunteers "might as well stay home."
When describing the benefits of coordination, one long-term foreign volunteer noted that the local healthcare provider could offer the short-term medical volunteer knowledge of resources, customs, and opportunities available to the local population. In addition, by coordinating with a long-term presence well in advance, many informants pointed out that the local contact is able to recruit patients for the volunteer group to see.
Additionally, coordination with a local, long-term presence is a legal requirement in Guatemala. In order for visiting healthcare providers to practice medicine in Guatemala, they are required to register with the College of Physicians and Surgeons (Colegio de Médicos y Cirujanos), providing evidence of credentials and a Guatemalan physician contact. Nevertheless, a number of Guatemalan health authorities and healthcare providers expressed concern that many groups of foreigners practice medicine in Guatemala without communication or coordination with the local healthcare system.
Meeting the Needs of the Community
Groups that do not work in coordination with a long-term presence frequently provide services that do not match the needs of the community. Many informants talked about "de-worming campaigns" in areas without clean drinking water sources; groups that provided free eye glasses without an eye exam; or groups that indiscriminately handed out vitamins as examples of particularly misguided interventions which reflect the lack of coordination and consultation with the local healthcare community.
Another detrimental effect of groups who practice in isolation is that services already provided by the Guatemalan community end up being duplicated by the volunteers. For example, we spoke with a Guatemalan physician working at a government health post in a community that was recently devastated by a natural disaster. His area regularly receives many foreign medical aid groups; however, "very few have actually come [to his health post] to ask about what is needed." He further described the problems with this lack of communication, citing an example of a short-term medical volunteer group who saw patients over a weekend and provided medications without any records or understandable explanations to the patients of why they needed the medication. He said those same patients came to his health post the following week, unable to explain what was done and why they were taking medication, forcing him to repeat their exams without any benefit to the patient or the system.
Many informants pointed out that at the very least, it is important to be in contact with local providers to ensure that what the volunteers are doing is actually needed and desired in the community. As one long-term foreign volunteer stated, "First understand if the people who you plan to help actually want it."
Follow-up care frequently came up in the context of why coordination with a long-term presence is important. As one interviewee pointed out, "Most problems take longer than one week to fix – without continuity, the care is not complete." In addition, many Guatemalan healthcare providers expressed willingness to provide the follow-up care to patients with whom they had personal contact, but stated that providing follow-up care to patients with whom they were unfamiliar could be problematic. Many informants suggested that one way to minimize incomplete care in the surgical field is to provide a record of what was done and why (in the appropriate language) to each patient, to the facility in which the surgery took place, and to the physician who will be responsible for the follow-up care.
One nonprofit private hospital was often cited as being particularly excellent at providing follow-up care. This hospital, through a small number of international NGOs with which they coordinate, hosted surgical teams from North America and Europe year-round and provided very low-cost surgeries to pre-screened patients who were in need. They involved Guatemalan surgeons and support staff in the surgery, and had patients return to that same hospital (where each patient's records were kept) for their follow-up care. They also hired a Guatemalan surgeon whose primary responsibility was to take care of post-operative patients and complications which arose from surgeries performed by foreign volunteers.
Resource and Information Sharing
Surprisingly, a number of the foreign volunteers were quick to point out that the benefits of short-term medical volunteer work may be greatest for the volunteers themselves. However, the majority of our Guatemalan informants (including healthcare providers, health authorities, and Guatemalans working on other health projects) as well as the long-term foreign volunteers also emphasized the fact that if coordination exists between visiting and local healthcare providers, these short-term medical interventions can be a positive experience for the local providers as well. Many Guatemalan informants described the educational opportunities for both sides when visiting teams work together with the Guatemalan providers. Others suggested educational exchanges between US and Guatemalan medical schools and sending the Guatemalan physicians to educational conferences as ways to provide mutually beneficial interactions.
The Guatemalan informants often cited the donation of equipment, medications, and supplies as one of the greatest benefits of short-term medical volunteer work. A Guatemalan ophthalmologist in private practice pointed out that:
There is a cost for the local ophthalmologist to provide follow-up care to patients who cannot pay for it, so there needs to be a reciprocal benefit to the relationship. Money is not the solution – that disappears and doesn't get to the patients. But, if volunteers leave something behind for the local physician, such as equipment, medications, operative instruments, or supplies that the physician could continue using when the volunteer group leaves, that benefits us and our patients.
It was often stated that donations amplify the impact of short-term medical volunteer work, as they improve the quality of services offered even after the volunteers are no longer present. However, the recipients of these donations often talked about the vast amount of expired medications they receive, which amount to what one interviewee referred to as "trash" that must be sorted through and disposed of, thus wasting valuable staff time. The argument that expired medications were "better than nothing" was not supported by our informants, as one interviewee commented, "If the medications aren't fit for human consumption in the US, why should they be fit for human consumption in a poor country?"
Quality of Care
Many of the foreign volunteers and volunteer coordinators focused on the issue of quality of care when practicing outside of one's own country. They talked about striving to provide the same quality of care as one would at home and working first and foremost out of responsibility and respect for the patient. As one long-term volunteer put it, "Always keep in mind that you are there to provide the best possible care for the patient – do things because the patient needs them, not for your own experience." They emphasized using good judgment in making medical decisions, including conservative patient selection for surgical cases. Many volunteers also discussed the importance of knowing your limits as a visiting physician and restricting your work to cases that are within one's technical limits and that fit the resources of the setting.
Along the lines of professional judgment, many informants (both Guatemalan and foreign) expressed concerns that some short-term medical volunteer groups may be trying to see too many patients per day at the expense of quality of care to the patients. Informants often worried that when volunteers focused on the number of patients seen per day, rates of complications increased, misdiagnoses and inappropriate treatment abounded, and patient education plummeted. In addition, the majority of our informants believed that religious and political discussion should be kept separate from the provision of patient care.