Many Hands Make Light(er) Work Developing Academic/NGO Partnerships to Enhance Global Health Projects Many Hands Make Light(er) Work

2012 AAFP Global Health Workshop Mark Ryan, MD President, HOMBRE Board of Directors; President Dominican Aid Society of VA VCU School of Medicine Department of Family Medicine Steve Crossman, MD Director, HOMBRE Board of Directors; COO VCU-Thundermist Pinares Project Jessica Evert, MD Medical Director, Child Family Health International UCSF Department of Family and Community Medicine Michael Stevens, MD, MPH Director, HOMBRE Board of Directors VCU School of Medicine Department of Internal Medicine

Objectives At the end of this session, participants will be able to describe the challenges faced by short-term global health engagements. explain how NGOs can enhance the impact of short-term medical projects and global health education. describe characteristics of successful partnerships with NGO’s. recognize ethical tenants that underwrite successful, sustainable, partnerships.

Why are the interest in global health? Student and faculty interests include: Altruism and service Clinical experience Research opportunities Student participants are: More likely to enter primary care More likely to work with public insurance More likely to work with underserved communities in the USA

Challenges in global health Transient participants Intermittent presence Insufficient preparation Lack of cultural competency Funding Relationship building Host community trust and involvement

Ethical framework Well-structured programs Explicit agreements Appropriate selection of trainees Formal training for program participants& trainees Development & implementation of safety protocols Comprehensive accounting of costs Transparency and information sharing Development & implementation of processes for formal feedback Focus on local needs and priorities Focus on mutual benefit Established long-term partnership Effective supervision and mentorship Compliance with standard guidelines and policies Adapted from: Crump JA, Sugarman J et. al., 2010. Global health training: ethics and best practice guidelines for training experiences in global health. Am J Trop Med Hyg 83: 1178-1182. Working Group on Ethics Guidelines for Global Health Training (WEIGHT), published recommendations in 2010

DR DR SOMOS VCU HOMBRE Fundación Sol Naciente Dominican Aid Society of Virginia SOMOS Fundación Sol Naciente VCU HOMBRE

DR Name Location Description Partner 1 Partner 2 Partner 3 Partner 4  Dominican Aid Society of Virginia  Richmond, VA US-based 501©3 non-profit with independent Board of Directors; emphasis on direct medical care and establishing relationships with local Ministry of Health and nonprofit healthcare providers in Dominican Republic Partner 2  Student Organization for Medical Outreach and Sustainability (SOMOS)  Williamsburg, VA University and course-based non-profit focused on participatory community development.  Based in social scientific theory and research to promote community partnerships and sustainable and long-term strategies for improving health and health care.    Emphasis on research and knowledge to promote and support social change. Partner 3  Fundación Sol Naciente Santo Domingo, D.R. Dominican non-profit founded in 1995. Partners with Physicians for Peace and provides direct free or low-cost medical services. Medical care provided at a healthcare center in eastern Santo Domingo Partner 4  VCU/HOMBRE Richmond, VA Supports the June medical/community development trip to Paraíso via HOMBRE, enhances continuity of care for the community, allows future development of academic and research partnerships. SOMOS: embodies “an effort in engaged scholarship that combines service learning, fundamental precepts, core concepts, a basic method, and a systematic approach to partnering to pursue long-term, small-step strategies to improve health and health-care in Paraíso, Dominican Republic”. FUNSI: Mission is to propel the harmonious development and integration of the people through the investigation and programs of Health and Education, in accordance with other related institutions, in the endeavor of creating a more just and fair society

DR +/- +/+ -/- +/- +/+ +/+ +/- -/- -/- Guideline DASV SOMOS FUNSI VCU/HOMBRE   Well-structured programs +/-  +/+  Explicit agreements -/- +/- Appropriate selection of trainees +/+  +/+ Formal training for program participants& trainees  +/- -/-  Development & implementation of safety protocols Comprehensive accounting of costs Transparency and information sharing Development & implementation of processes for formal feedback Focus on local needs and priorities Focus on mutual benefit Established long-term partnership Effective supervision and mentorship Compliance with standard guidelines and policies  -/- DASV: ongoing collaborative relationships, but less formalized re: MOU, formal protocols, policies, etc. Focus has been on securing meds/supplies and coordinating volunteers who travel as individuals collaborating on a project. More formal relationships, agreements, protocols would be an area of focus. SOMOS: strong student organization and student leadership; university oversight leads to a formal program and oversight. Less emphasis on MOUs. FUNSI: role focused on in-country logistics and collaboration in clinical care. Organization may have strong internal protocols, etc. but little formal interaction with medical service teams aside from shared care. VCU/HOMBRE has an effective, organized structure that addresses each of these areas effectively. Adapted from: Crump JA, Sugarman J et. al., 2010. Global health training: ethics and best practice guidelines for training experiences in global health. Am J Trop Med Hyg 83: 1178-1182. Code: +/+ = guideline achieved well +/- = guideline marginally achieved -/- = guideline not adequately achieved yet

Norte, Honduras Norte Golden Phoenix VCU (NPH) HOMBRE

Norte Name Location Description Partner 1 Golden Phoenix Foundation United States  Non-profit focused on issues around international adoption. Dr. Mason, physician co-site leaders for Norte, is the physician director of Golden Phoenix. They sponsors our water filter project. Partner 2 Nuestros Pequenos Hermanos (NPH) Honduras and International  Organization has contributed to our medical and public health mission in Yoro with contributions of personnel and supplies. Dr. Mason works with the NPH group and this is the origin of NPH’s support of our mission in Yoro. Due to geographic limitations, the NPH orphanage group is no longer involved in our Yoro work (as of 2012, were involved 2008-2011). Partner 3 HOMBRE United States Non-profit, also a VCU medical student interest club. Provides VCU medical and pharmacy students opportunities to rotate on our health brigade in Yoro. Also helps fund medication and supplies for brigades. Partner 4 VCU Primarily involves the Global Health & Health Disparities (GH2DP) program within the Department of Internal Medicine. Also the Department of Pediatrics at our Inova Fairfax campus.

Norte +/- +/+ +/+ +/- -/- +/+ +/- Guideline Golden Phoenix HOMBRE VCU   Well-structured programs +/- +/+  Explicit agreements +/+ Appropriate selection of trainees Formal training for program participants& trainees +/-  Development & implementation of safety protocols Comprehensive accounting of costs Transparency and information sharing Development & implementation of processes for formal feedback -/- Focus on local needs and priorities Focus on mutual benefit  +/+ Established long-term partnership Effective supervision and mentorship Compliance with standard guidelines and policies  +/- Adapted from: Crump JA, Sugarman J et. al., 2010. Global health training: ethics and best practice guidelines for training experiences in global health. Am J Trop Med Hyg 83: 1178-1182. Code: +/+ = guideline achieved well +/- = guideline marginally achieved -/- = guideline not adequately achieved yet

Shoulder to Shoulder, Inc. Pinares, Honduras Pinares Hombro a Hombro Shoulder to Shoulder, Inc. VCU / Thundermist Comite’

Pinares Name Location Description Partner 1 Virginia Commonwealth University, Department of Family Medicine; Thundermist Health Center (VCU/T) Richmond, VA; Woonsocket, RI An academic family medicine department with dynamic medical student programs as well as five affiliated family medicine residency training programs in Virginia; a large federally qualified community health center in Rhode Island Partner 2 Shoulder to Shoulder, Inc. (S2S) Cincinnati, Ohio An international NGO based in the United States which works to serve the poor in multiple countries on multiple continents Partner 3 Hombro a Hombro (HaH) Intibuca, Honduras The Honduran NGO affiliate of Shoulder to Shoulder which works with their affiliates whose projects are in Honduras. Partner 4 Pinares Health Comite’ (Comite’) A local committee of village volunteers that partners in managing the clinical and public health projects undertaken in these communities

Pinares +/+ +/+ +/+ +/- +/- -/- -/- -/- +/+ -/- +/- Guideline VCU/T S2S HaH Comite’   Well-structured programs +/+   +/+  +/+   +/-  Explicit agreements +/-  -/-   -/- Appropriate selection of trainees Formal training for program participants& trainees  -/-  Development & implementation of safety protocols +/+ Comprehensive accounting of costs Transparency and information sharing -/-  Development & implementation of processes for formal feedback Focus on local needs and priorities Focus on mutual benefit Established long-term partnership Effective supervision and mentorship +/-   Compliance with standard guidelines and policies Adapted from: Crump JA, Sugarman J et. al., 2010. Global health training: ethics and best practice guidelines for training experiences in global health. Am J Trop Med Hyg 83: 1178-1182. Code: +/+ = guideline achieved well +/- = guideline marginally achieved -/- = guideline not adequately achieved yet

CFHI 20 yr old US-based NGO 20 explicitly educational programs in 5+ countries Asset-based engagement Consistent professional structure at each site Local Medical Director Local Coordinator Preceptors 600+ students/residents annually Institutional partnerships with medical, undergraduate, health-science schools “Out-sourcing” of sustainable partnerships, risk, contract negotiations, incident management, safety policies, eval./assessment & program management

CFHI’s 20+ Global Sites SOUTH AFRICA BOLIVIA INDIA ECUADOR MEXICO HIV/AIDS & Healthcare- Durban Healthcare Challenges- Cape Town BOLIVIA Chagas- Tarija Pediatric Health- La Paz INDIA Sight for All- Ophthalmology Rotation- New Delhi Rural/Urban Community medicine- Rural Himalayas Intro to Traditional Medicine- Rural Himalayas Communicable Disease- Mumbai HIV & Public Health Challenges- New Delhi Maternal and Child Health- Pune Hospice and Palliative Care in Southern India ECUADOR Vector-borne Diseases- Amazon Andean Health- Quito Urban & Rural Comparative Health- Quito/Chone Reproductive Health-Quito Community Medicine-Amazon Indigenous Health- Amazon Sonrie Dental Program- Quito MEXICO Cultural Crossroads in Health- Oaxaca Tropical Medicine & Rural Health- Puerto Escondido Women’s Reproductive Health- Puerto Escondido

CFHI “Standard” programs accessible by individual students 10+ “Institutional partnerships” which customize to specific academic institutions Avoids the wavering support of administration, unreliable funding streams, change in resources & commitment to global health Downside of tuition-based is less accessible to students without means & ability to fundraise Educational rather than service mission ‘Service’ & reciprocity provided through a professional development/community health grants program that is under local control

Perseverance through political unrest/instability CFHI Annual contracts negotiated with individuals and organizations / clinical sites Programs all have ‘themes’ determined by partner’s/community’s strengths Guideline CFHI Partnerships   Well-structured programs  +/+ Explicit agreements Appropriate selection of trainees  +/- Formal training for program participants& trainees +/-  Development & implementation of safety protocols +/+  Comprehensive accounting of costs Transparency and information sharing Development & implementation of processes for formal feedback Focus on local needs and priorities Focus on mutual benefit Established long-term partnership Effective supervision and mentorship Compliance with standard guidelines and policies Annual report and clear tuition costs and per capita fees paid to partners/clinics Focus on local strengths / assets & reciprocity / professional development focuses on needs/deficits Challenge of preceptors wanting students to ‘really like it’ and allowing them to act beyond training Perseverance through political unrest/instability Adapted from: Crump JA, Sugarman J et. al., 2010. Global health training: ethics and best practice guidelines for training experiences in global health. Am J Trop Med Hyg 83: 1178-1182. Code: +/+ = guideline achieved well +/- = guideline marginally achieved -/- = guideline not adequately achieved yet

Benefits of NGO partnerships Ongoing community relationships Participant preparation Project facilitation Cultural brokers Fundraising

Challenges to academic/NGO partnerships Sustainability Differing organizational cultures Staff changes Ethical challenges Funding

Conclusions Partnerships with NGOs can: Enhance the safety Enhance effectiveness Improve sustainability These partnerships face many challenges, but a robust ethical framework increases likelihood of continued success

Partnerships and collaborations