Non-Governmental Organization’s (NGOs) Impact on Health Care Services in Rural Honduras: Evaluating a Short–Term Medical Mission (STMM) Utilizing a Case Study Approach by Patti L. Tracey A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy Graduate Department, Lawrence S. Bloomberg Faculty of Nursing University of Toronto Copyright by Patti Lynn Tracey 2015 Patti Tracey, Doctor of Philosophy, Nursing, University of Toronto, 2015 Abstract Non-Governmental Organization’s (NGOs) Impact on Health Services in Rural Honduras: Evaluating a Short-Term Medical Mission (STMM) Utilizing a Case Study Approach Canada is a leading, international country that engages in Non-Governmental Organization (NGO)-led STMMs to low and middle-income countries for the provision of health care, education or structural development. Honduras, a chief destination country, is one of the poorest, most politically unstable in Central America. Health expenditure is among the lowest in the Americas, approximately 30.1% of the population receives no health care, and there is marked exclusion of ethnic and rural minorities. In Honduras, there is a paucity of evidence on the expectations, coordination and outcomes of STMMs. Guided by World Health Organization’s Primary Health Care (PHC) framework, an exploratory, type 2, single case study with a multiple embedded units design was used to address two research questions relating to the processes and outcomes of STMM services, and how stakeholders assess services. Eight propositions supported the data collection and a 12-day STMM involving 7 rural villages in Gracias a Dios (client n = 1120) constituted the case over three time periods (pre, during, and 10-weeks post STMM). Other data sources were key stakeholders (regional health/host officials, Honduran and Canadian health care providers). A revised, adapted Harvard evaluation tool was the principal data collection instrument. According to a review of English publications, this is the first longitudinal assessment of STMM processes, outcomes and community perspectives. ii Community members provided rich details regarding factors that impact their health, such as their impoverished situation and environmental challenges and risks (water, sanitation, food scarcity, poverty, and limited transportation). Diagnoses and treatments were consistent with the evidence of predominant health issues and medications provided in similar regions. Due to limited resources and/or unavailability of services STMM, clients had no opportunity to follow up on referrals. The results suggest that the existing STMM model is limited to adequately meet the needs of the people living in a rural and remote region of Honduras where poverty is extreme. The discussion situates the findings within the context of a country where, despite individuals’ constitutional right for health, political instability and multiple, intersectoral complexities challenge such right and reveal that STMM’s contributions are valued but fragmented with largely unknown outcomes. Recommendations for STMM quality and accountability, policy, education, and future research are presented. iii Acknowledgements This thesis, while revealing, is only the beginning of a much larger journey and requirement for quality and evaluation of the role and impact of Short–Term Medical Missions (STMMs). This adventure, like most adventures was wonderful and exciting however, it also pushed me well beyond what I thought was ever possible. It forced me to think in an inherently different manner about the role of STMMs in low and middle-income countries. I would like to thank my supervisor, Dr. Carles Muntaner for his dedication and knowledge. You have taught me to challenge the status quo, focus more on solutions than on problems and intimately understand the politics of health. I would also like to thank and acknowledge my esteemed committee members, Dr. Denise Gastaldo and Dr. Alexandra Martiniuk, both of whom I respect and admire very much. In addition to my PhD committee, I would like to thank Dr. Janet Rush for her support, friendship and angel-like guidance during my dissertation process. My friends and colleagues at the Lawrence S. Bloomberg Faculty of Nursing, the Dalla Lana School of Public Health and Trent University, all of whom formed an incredible support system for me. A special thank you to Dr. Kirsten Woodend, Dr. Jane Mackie and Dr. Raymond Dart. I would like to thank my family who both cheered me on and left me to my private spaces when and as needed over the years. Most especially, Craig, Emma, Jacob, and Abigail. I credit my father, Peter Hamilton for my relentless determination and perseverance to finish this journey. He taught to never give up and finish what you started. Both required qualities in a PhD student. I extend the grandest gratitude to the people of Honduras and in particular the people in the region of Gracias a Dios. Without your honesty, time and commitment to this study, it would not have been possible to complete. Terry Dario, Dr. Luis Everett, Dr. Fabio Caballero Cerna, Arturo Caballero Cerna, Grazia Tedeschi, David Venegas and Wilmer Meza. A special thank you goes to Carlos Aguilar (Churri), my friend and interpreter during my PhD adventure. You literally carried me through “La Mosquitia” and back again. You never let me quit moving forward and showed me the importance of sharing this research with the world. Finally, my heartfelt thank you, gracias y tinki pale goes to the study participants for allowing me into your lives. Your strength, words and stories have illustrated to the world the explicit needs and urgent primary health care requirements in rural Honduras. This thesis is dedicated to the memory of my mother, Marylin Grace McConnell. I know you will be smiling down on me as I walk across the stage to receive my diploma. iv Table of Contents Abstract … ii Acknowledgements ….iv List of Abbreviations .. viii List of Figures … x List of Tables … xi CHAPTER 1 INTRODUCTION … 1 SECTION 1.1 THE PROBLEM AND RELEVANCE … 3 SECTION 1.2 THE PURPOSE AND RESEARCH QUESTIONS … 6 CHAPTER 2 BACKGROUND … 7 SECTION 2.1 DEFINING KEY CONCEPTS … 7 Subsection 2.1.a Non-Governmental Organizations … 7 Subsection 2.1.b Short-Term Medical Missions … 9 SECTION 2.2 COUNTRY CONTEXTS: NATIONAL AND REGIONAL … 11 Subsection 2.2.a Political and Geographic Context … 11 Subsection 2.2.b Demographic and Health Status … 15 Subsection 2.2.c Health Care in Honduras … 20 Subsection 2.2.d Health Care in the Department of Gracias a Dios … 26 CHAPTER 3 LITERATURE REVIEW … 29 SECTION 3.1 SCOPING REVIEW OF THE LITERATURE … 29 SECTION 3.2 NON-GOVERNMENTAL ORGANIZATIONS AND PRIMARY HEALTH CARE AND CENTRAL AMERICA … 32 Subsection 3.2.a Search Strategy … 32 Subsection 3.2.b NGOs as Agents of Development in Health … 32 Subsection 3.2.c. Costs and Funding of NGOs … 34 Subsection 3.3.d NGOs and the Impact of Health Outcomes … 37 Subsection 3.3.e NGOs as Collaborative Partnersin Health … 41 SECTION 3.3 SHORT-TERM MEDICAL MISSIONS (STMMs) AND CENTRAL AMERICA …43 Subsection 3.3.a Search Strategy … 44 Subsection 3.3.b STMMs: The Current Reality … 46 Subsection 3.3.c Medical Missions: General … 47 Subsection 3.3.d Medical Missions: Honduras … 49 Subsection 3.3.e Patient Perceptions: Central America … 51 SECTION 3.4 RESEARCH IN GRACIAS A DIOS, HONDURAS … 55 SECTION 3.5 MONITORING AND EVALUATION … 57 CHAPTER 4 CONCEPTUAL FRAMEWORK … 63 SECTION 4.1 STMMS-RATIONALE FOR EVALUATION … 64 SECTION 4.2 PRIMARY HEALTH CARE (PHC) … 66 v Subsection 4.2.a Selective Primary Health Care … 70 Subsection 4.2.b Primary Care … 71 Subsection 4.2.c Health and Human Rights Approach … 72 SECTION 4.3 PRINCIPLES OF PRIMARY HEALTH CARE … 73 Subsection 4.3.a. Universal Access … 79 Subsection 4.3.b. Equity … 81 Subsection 4.3.c. Community Participation … 84 Subsection 4.3.d. Intersectoral Approach … 85 CHAPTER 5 METHODS AND DESIGN … 88 SECTION 5.1 SINGLE CASE DESIGN RATIONALE … 89 SECTION 5.2 THE CASE … 91 SECTION 5.3 SETTING … 93 SECTION 5.4 SELECTING THE VILLAGES … 93 SECTION 5.5 CASE STUDY DESIGN: CONNECTING COMPONENTS … 94 Subsection 5.5.a Orientation to the single case … 95 Subsection 5.5.b Research study questions … 96 Subsection 5.5.c Study propositions … 97 Subsection 5.5.d Unit of analysis … 98 Subsection5.5.e Logic linking propositions to Data collection … 98 SECTION5.6 SOURCES OF EVIDENCE … 100 SECTION 5.7 DOCUMENTATION … 102 SECTION 5.8 SURVEY QUESTIONNAIRES: HEALTH IMPACT ASSESSMENT FOR STMMs … 102 Subsection 5.8.a Strengths of the Harvard Model. … 105 Subsection 5.8.b. Limitations of the Original Harvard Model … 106 Subsection 5.8.c. Evaluation of STMMs: The Revised Harvard Model … 108 Subsection 5.8.d. Minor Revisions … 109 Subsection 5.8.e. Major Revisions … 112 SECTION 5.9 INTERVIEWS … 113 Subsection 5.9.a. Sample size … 115 SECTION 5.10 DATA ANALYSIS … 116 SECTION 5.11 ETHICAL CONSIDERATIONS … 120 Subsection 5.11.a. Privacy and Confidentiality … 120 Subsection 5.11.b Risks and Benefits … 121 Subsection 5.11.c Compensation … 122 CHAPTER 6 RESULTS … 123 SECTION 6.1 COMMUNITY MEMBER PERSEPECTIVES … 124 SECTION 6.2 SOCIO-DEMOGRAPHIC CHARACTERISTICS OF STMMs CLIENTS … 130 Subsection 6.2.a. Village Information … 130 Subsection 6.2.b. Age and Gender … 131 Subsection 6.2.c. Education … 131 Subsection 6.2.d. Income and Poverty … 132 vi SECTION 6.3 CONTEXT OF STMM … 132 SECTION 6.4 PROCESSES AND OUTCOMES OF HEALTH SERVICES DELIVERED BY A STMM … 134 Subsection 6.4.a. Proposition 1: Findings … 136 Subsection 6.4.b. Proposition 2: Findings … 140 Subsection 6.4.c. Proposition 3: Findings … 142 SECTION 6.5 STAKEHOLDER ASSESSMENT OF HEALTH CARE SERVICES PROVIDED BY A STMM … 146 Subsection 6.5.a. Proposition 4: Findings … 149 Subsection 6.5.b.