Elements of a good health system are lacking in most low- and middle-income countries (LMICs) and in many high-income countries, including the United States. A major problem is financing health care. On average, about 50% of healthcare financing in low-income countries comes from out-of-pocket payments, compared to 30% in middle-income countries and 14% in high-income countries.
Elements of a good health system are lacking in most low- and middle-income countries (LMICs) and in many high-income countries, including the United States.
A good health system delivers quality services to all people, when and where they need them. The exact configuration of services varies from country to country, but in all cases requires a robust financing mechanism; a well-trained and adequately paid workforce; reliable information on which to base decisions and policies; well-maintained facilities and logistics to deliver quality medicines and technologies. (World Health Organization, 2017, para. 1)
A major problem is financing health care. On average, about 50% of healthcare financing in low-income countries comes from out-of-pocket payments, compared to 30% in middle-income countries and 14% in high-income countries (Mills, 2014). Even if a social health insurance program exists, cancer screening, early detection, and treatment are not always covered services. In many LMICs, a two-tier system of health care exists—public (government) facilities, which are seriously under-resourced, and private/corporate facilities with better resources for the few who can afford them. The public system is structured step-wise so that complicated cases are referred to a higher-level facility. Gaps in the system are filled by private and faith-based nongovernmental organizations.
The LMIC healthcare workforce may include lay health workers, who provide basic health education and oversee medication compliance in their community, and midlevel providers, such as clinical officers, who staff health centers and district hospitals. Specialist physicians, such as oncologists, usually are found only in national referral hospitals, and typically only one such hospital exists in the country’s capital city. Nurses have variable training from a secondary certificate (two years) to a bachelor’s degree (Malvárez & Castrillón, 2005; Munjanja, Kibuka, & Dovlo, 2005). There are few opportunities and many barriers to advanced nursing education, specialty certification, or continuing professional development. In many LMICs, nursing is generally considered a low-status occupation, a view often held beyond the healthcare system, extending to the public and policymakers. Nursing’s contribution to patient care is subsequently undervalued. Advanced practice and specialist nurses may exist but are restricted in their scope of practice (All-Party Parliamentary Group on Global Health, 2016). Multiple factors contribute to these issues, including the dominance of the medical profession, gender-based inequities, cultural taboos related to the intimacy of bodily care, and the undervaluing of direct hands-on care and emotional support. Inspiring examples of nurses overcoming these challenges exist, such as in Zambia where specially trained nurses run cervical cancer screening clinics (Mwanahamuntu et al., 2011), Botswana where nurses prescribe antiretroviral drugs (Miles, Clutterbuck, Seitio, Sebego, & Riley, 2007), and Uganda where nurses prescribe and dispense morphine (Jagwe & Merriman, 2007).
There may be little awareness about cancer signs and symptoms in the general population and few screening or early detection programs. Serious stigma often surrounds a cancer diagnosis, particularly for women if the cancer involves parts of the body related to reproduction (e.g., cervical cancer, breast cancer), and can contribute to fatal delays in seeking treatment. As a result, patients often present with advanced and incurable disease. Cancer treatment services, such as chemotherapy and radiation therapy, if available, are usually limited to government referral hospitals in urban areas. These facilities are significantly overcrowded; multiple patients may share a bed, and there are often long waits to be seen by the oncologist and scheduling delays for surgery or radiation therapy. There may be no ancillary services, such as dietary services, respiratory therapy, physical therapy, or social work. Basic supplies, such as hand sanitizer, gloves, and alcohol wipes, are often scarce or absent. Equipment can be old, outdated, or nonfunctional. Cancer chemotherapy drugs may be unavailable in the hospital, even if they are included in the Ministry of Health essential medicines list. Patients must then purchase these medications from itinerant pharmaceutical sellers or local pharmacy shops where the quality of the drug cannot be assured. Nurses and pharmacy technicians may mix and administer chemotherapy without access to personal protective equipment or safety hoods. Pain is usually managed with nonsteroidal medications because opioids are rarely available. When opioids are available, they are often prescribed in a limited manner with multiple bureaucratic requirements and restrictions. Medical records are commonly paper-based and include minimal information. Nurses rarely document the care delivered other than medication administration. There are often no written standards of practice or formal treatment protocols. Disclosure of diagnosis may not be the cultural norm; this may present ethical dilemmas for volunteers accustomed to a Western approach to health care.
Critical to success as a volunteer is finding the right opportunity—one that will best fit a person’s strengths as an oncology nurse. Opportunities exist to provide clinical care, teach students or practicing nurses, consult for an organization or health system, or do research in collaboration with in-country nurses (see Figure 1). National Cancer Institute–designated cancer centers and schools of nursing may have relationships with clinics or hospitals abroad that enable their staff and students to volunteer at these sites. It is essential to read about the organization, check its legitimacy and credentials, and ask, “Is this the kind of work and organization I want to be associated with?” Contact and communicate with the organization early, at least several months prior to your planned trip. Do not just “drop in” to offer services to an organization and expect to be well received. Be extremely wary of “voluntourism” opportunities that expect large payments and promise to deliver a “real” culturally enriching experience; many operate under dubious circumstances and exploit local communities.
Potential volunteers should explore the time commitment for an assignment, including time needed for tasks like obtaining a passport, visa, vaccinations, developing presentations, and gathering books or supplies to be donated to the site. Most assignments require a minimum of two to four weeks; some commitments are as long as a year. Many organizations prefer longer-term volunteers (weeks to months); if you can volunteer only for a short time, ensure that is useful and beneficial to the organization. Expenses vary but are about $3,000 for airfare, lodging, and meals for a two-week assignment. Costs for passport, visa, vaccinations, and antimalarial medications (if required) need to be considered as well. Volunteer assignments will be most meaningful and successful when they involve sustained, longitudinal, respectful partnerships designed to meet the needs of local partners and collaborators.
It is always helpful to understand the needs, challenges, and gaps in knowledge beforehand and to prepare and plan for the project. Ask the local host what they need. It is important to understand the language (at a minimum, a basic working knowledge of key phrases), culture, religious beliefs, legal paperwork required, safety concerns, and etiquette about clothing and appearance to live and work comfortably in a country. Be prepared for assignments to be physically demanding. Heating or air conditioning, hot water, electricity, and Internet service may be unavailable or unreliable.
Volunteers should check with the site before obtaining books, journals, supplies, or equipment to donate. Sometimes supplies that seem like they will be helpful can actually be problematic if there is no way to ensure continued availability. Many healthcare providers in LMICs have limited, if any, access to current medical and nursing journals, so they may be particularly appreciated, but be sure to check ahead of time. Donated books should be current editions, and journals should be less than two years old. Recent copies of Clinical Journal of Oncology Nursing and Oncology Nursing Forum can be obtained for distribution by global volunteers at no charge by emailing pubCJON@ons.org. However, it is important to remember that, even if nurses have been trained in English, journals and texts written in English may be difficult for most nurses to understand. Donated equipment should be in working order, and the site should have the ability to repair it or obtain replacement parts.
Learn about the healthcare system and cultural beliefs and practices surrounding a cancer diagnosis and treatment; medical anthropology journals can be particularly helpful for the latter. Familiarize yourself with basic information about the country’s cancer burden regarding incidence, mortality, and the most common cancers (see Figure 2). For example, is there is a cancer registry? Is there a cancer control plan, and what does it say? What is the availability of radiotherapy? Is it a cobalt or a linear accelerator? What prevention measures and screening initiatives exist?
To volunteer in an LMIC is unlike anything healthcare providers will experience in the Western world. The language, sights, sounds, smells, and cultural differences can be overwhelming. It is advisable to spend at least a few days adjusting to the new surroundings before beginning your assignment.
Respect the local context: Most of the places that need volunteers are resource-scarce settings, each one uniquely different from another. A successful volunteer should be able to recognize the setting’s limitations and work on solutions or alternatives to help the situation. Be prepared to be flexible and ready with the most basic level of activities. For example, an oncology nurse from Canada traveled to India to volunteer with a pediatric oncology program. She came with the intention to train and empower the oncology nurses with skills in chemotherapy administration but soon realized she needed to start with the basic importance of handwashing. In Bhutan, the oncology unit in the national referral hospital is a comparatively new unit and the only one in the entire country. Very few nurses are properly trained in cancer care, and the unit was lacking oncology educational resources. Over several years, oncology nurse volunteers helped to fill these gaps by giving classes and presentations for the Bhutanese nurses, donating oncology reference books, and introducing staff members to helpful websites on cancer care.
Interpersonal and communication skills: There may be little or no in-the-field oversight or supervision of volunteers, so it is critical to be independent and flexible, with strong interpersonal and problem-solving skills. Every setting will have people and professionals from varied backgrounds and cultures working together. These differences can sometimes create gaps in the continuum of good health care given to the patients. A successful volunteer should be able to communicate effectively with all members of the interprofessional team and sometimes act as a mediator to provide the best cancer care to the patients. In other words, the volunteer needs to be open-minded, flexible, patient, and a good communicator with strong interpersonal skills. A volunteer also should be sensitive to differences in health and the sociocultural/political environment and be ready to adapt and facilitate change accordingly. These skills will help the volunteer connect with the local team and community.
Share knowledge and make positive contributions: Strong cancer content knowledge and several years of relevant experience are essential for volunteers. Expertise in palliative care, end-of-life care, and complex wound management is particularly helpful. A successful volunteer is equipped not only with strong cancer content knowledge, but also with updates from the latest research or innovative discoveries in the field. Sharing this knowledge can encourage LMIC providers to be more open-minded and create a more professionally disciplined setting. For example, volunteers in Bhutan helped to develop protocols for the safe administration of chemotherapeutic agents, side effect management, and patient follow-up. These protocols are reviewed quarterly, each time a new volunteer comes, for changes and updates.
Follow-up and availability: Many good volunteers bring about significant improvements during their time in the field. However, very few follow up after their volunteering period. A few volunteers email occasionally to check on changes and new developments, offer professional advice and guidance, and make themselves available after their volunteer work has ended; this is a beautiful characteristic of a truly successful volunteer.
Global oncology volunteering can be an effective way to share expertise and gain cultural knowledge and perspective. At its best, global oncology volunteers engage in respectful, sustainable efforts that are relevant to the in-country context. LMIC oncology volunteers who have successfully made a lasting, positive contribution are those who have strong cancer care knowledge and excellent interpersonal skills and are very open-minded, knowledgeable, polite yet assertive, creative, and innovative in helping to create an effective and disciplined system of healthcare services for patients with cancer.
Galassi is a nurse consultant for Armand Global Consulting in Rockville, MD; Pradhan is a clinical nurse at the Jigme Dorji Wangchuck National Referral Hospital in Thimphu, Bhutan; Palat is a director of palliative care for the MNJ Institute of Oncology and Regional Cancer Centre in Hyderabad, India, and the Two Worlds Cancer Collaboration (INCTR Canada) in Vancouver, British Columbia, Canada; and LeBaron is an assistant professor in the School of Nursing at the University of Virginia in Charlottesville. No financial relationships to disclose. Galassi can be reached at firstname.lastname@example.org, with copy to editor at ONFEditor@ons.org.
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