Sustainable church hospitals

A little publication in 1998 surveyed 43 church-related mission hospitals to identify criteria for sustainability.  They identified nine critical success factors in the process:

  1. Vision/mission/objectives. These hospitals had a Christ-centered vision that had been translated into ‘do-able’ mission statements and behavioral objectives to guide board and staff members at all levels in their day to day work. They were actively revisited at induction training sessions, retreats and other meetings.
  2. Visionary governance. There was appropriate representation of various stakeholders, availability of the range of expertise needed, and availability of the experience required to set up policy guidelines to help the institution in business dealings, etc.
  3. Dynamic technical and managerial leadership. Careful selection of managers and supervisors was reinforced by training, nurtured by prayer, and tested on a continuing basis by application at work. The board showed active interest and demanded accountability at reasonable and regular intervals. These leaders, in their daily interaction with people at all levels and all classes of society, demonstrated commitment to Christian values and determination to live them in words and actions. (Hurrah!)
  4. Reputation for quality of care. These hospitals had a long standing reputation for excellent care in their particular areas of expertise. In many cases this reputation was built by missionary doctors and related staff many decades ago but had been maintained by successors, and continues to serve as a magnet and beacon for patients.  This boosted outpatient visits to an optimum of about 150 per day and filled beds to at least 60 percent capacity; this in itself appears to enhance survival.
  5. Adequate quantity, quality and stability of staff.  These hospitals had adequate numbers of well-trained staff, especially in the strongest specialties. This generated patient confidence. Innovative strategies to reward and retain staff appear very important. Ensuring local access to quality education for staff children was also vital.
  6. Solid financing and financial administration. Key characteristics of the ‘successful’ hospitals were the capacity to generate good revenue, atract local funds and external donations and grants, disburse them wisely, and account for them consistently with generally accepted financial practices. This earned them confidence with stakeholders, patients, governments and donors.
  7. Viable location. Some were in urban areas and able to have clientele who earned money, and others were in rural areas where local people lived near active markets, making incomes reasonable to sustain the hospitals and still serve those who were not able to pay.
  8. Church commitment to health ministry. Possibilities of sustainability were greatly enhanced in situations where churches had inherited hospitals from missionaries but had made firm commitments to to operate them, drawn up clear policies and made it a priority to provide for them financially and materially. Such churches expected to be net contributors to the hospitals, seeing them as part of their Christian outreach or mission. Churches which viewed ‘their’ hospitals as a source of income, taking money out of them whenever possible, tended to be less successful.
  9. Government policies conducive toward private providers. Sustainability was improved when governments made provision for selected para-pubic institutions such as church hospitals to be integrated into the national health network of services, while leaving the churches free to make their own capital development and administrative policies. In these situations, the governments made substantial recurrent-cost contributions to the hospitals concerned, thereby decreasing their running costs and making them more viable.

In planning for successful handover from foreign (or mission) ownership to local, these success criteria can give us a helpful roadmap. Although one may not be able to do much about changing the location of a hospital, plans can develop leadership for many other aspects, such as:

  • Maintaining a Christ-centered vision for ministry
  • Careful attention and planning for good governance
  • Development of leadership both on the technical managerial side as well as the clinical side of services
  • Planning for staff development, including attention to all of life (relational, spiritual and family — even education of children!)
  • Solid financial systems and accountability
  • Developing church leadership which knows Scripture well and can embrace ministry of Word and deed, without neglecting either one. (For centuries the church has been active in giving sacrifically to serve the poor).
  • Advocating with government on policy or larger country-wide issues, especially when it comes to caring for the marginalized and brokenhearted — see Isaiah 61:1)

Community based approaches to primary health care

When I studied international and community health at Johns Hopkins in 1977, primary health care was a new emphasis. Our dean, Dr. Carl Taylor led a department full of passion about reducing illness and promoting health through primary care. But the amount of data about this approach was limited. Like many others, I found that the dream was charming, but not so easily implemented when I went to Ethiopia.

So I was encouraged to hear that now there are over 700 studies in the medical literature which support community based primary health care. Dr. Henry Perry and others at Johns Hopkins have published their findings in the Journal of Global Health here.

The evidence supports CBPHC as an important component of a comprehensively-designed maternal and child health program, not just for the direct effects on maternal and child morbidity and mortality, but because of its contribution to appropriate usage of hospital and clinic facilities. In other words, we need a balance of curative, preventative and promotive.  The evidence is clear.

Here are some aspects of CBPHC:

  • Engagement of women’s groups
  • Innovation like puppet shows
  • Paid and unpaid local workers and volunteers
  • Strengthening the staff of peripheral health centers
  • Using both medical professionals and non-professionals in complementary ways
  • Regular home visits
  • Community based case management
  • Mobile teams

Dr. Perry points out that belief in curative medicine is very powerful; sometimes we are mesmerized by technology and curative care. While they have a very important place, we also know that a large percentage of illness can be mitigated, prevented or treated by non-medical means. We want to embrace good clinical care, of course, but balance this with sustained and intentional efforts to impact communities in broader, more ‘non-technical’ ways. CBPHC may not be technologically sophisticated, yet it can be powerful.

In terms of social justice, Perry points out the CBPHC can have a ‘pro-equity’ effect, avoiding the potential barriers to health care that institutions by themselves can have.

As we make disciples in our healthcare missions, let us remember to raise up both medical professionals and non-professionals, staff who work in institutions as well as those who work in communities.  With needs pressing in around us, we must keep hospitals functioning well yet not consume all of our resources on them — but balance clinical care (tertiary and secondary care) with community based primary health care. We need not only doctors, but social workers, health promoters, and grandmothers who are willing to make the sacrifice to love and invest in communities in order to bring healing to the brokenhearted and hope to those suffering around us.

If we are outsiders to a culture (expats or missionaries) we shouldn’t be naive about the difficulty of such an approach. It often touches on deeply held values, dreams, and cultural approaches which are distorted by our own rebellion from God and the ways of His kingdom. But as we love individuals and learn to serve side-by-side in humility with local people, we can discover how great is our Lord Jesus and enable many to find fullness of life in Him.

Mastery And Mystery

Scott spoke to us at the annual Mental Health and Missions conference in Indiana last month. As health professionals we live in the tension between mastery and mystery, and he helps us live there with his story of grace.

Tending Scattered Wool

We seek competency and proficiency in many areas of our lives. That is good and proper stewardship of what God has graced us with in life. As caregivers, it behooves us to provide as excellent of care as we can.

We feel most comfortable discussing and pursuing mastery. Mystery, though, is another reality IMG_0785.JPGaltogether…

Its the mysteries in life that undo us.

Mysteries are the life circumstances in which we often feel stuck, confused, and undone. We cry out to God for relief and nothing seems to change. Even the Apostle Paul experienced God saying “no” to him when he cried out for help (see 2 Corinthians 12 for example).

Tolerance for Mystery
God seeks to grow us in our tolerance for mystery. As we grow in tolerance for mystery, we actually become more competent in our mastery. However,  we often, sometimes unknowingly, ignore and hide the broken places…

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Social concern by evangelicals in the 1800s

Once in a while it is good to remind ourselves that Bible believing Christians over the centuries have been in the forefront of social concern, demonstrating the character of Jesus by good works of compassion.  Things changed somewhere in the early 1900s, but especially before that the church was a model for many social programs.

In Glasgow, Scotland, Thomas Chalmers operated a church school in the early 1800s, with an aim of lifting up the lives of children who had no access to education. His church also took on responsibility “for raising and distributing poor relief in its parish.”*

“In a society without state social welfare provision, a large range of philanthropic effort was undertaken by churches and Christian organizations. Children were a particular focus of concern. Education was largely in the hands of the churches until the State began its own efforts in the 1870s. Anglican and Catholic orphanages were widely established. The London Congregational minister Andrew Reed (1787-1862) started three orphanages, a hospital for children with severe learning difficulties and a home for people with incurable illness. George Muller’s Ashley Down Orphanage supported some 2,000 children in Bristol in the 1880s. In the East End of London, Thomas Barnardo (1845-1905), who started a mission for young people, had by the time of his death rescued around 60,000 children. He pioneered approaches to fostering, operating a ‘no destitute child refused admission’ policy. In 1905 Barnardo’s children’s homes were caring for over 8,500 children, of whom 1,300 were disabled or suffering from serious illness.

“One of Britain’s most widely respected philanthropists and social reformers was Lord Shaftesbury (1801-85). He was strongly motivated by his evangelical social conscience, and steered legislation through Parliament to outlaw the employment of children in underground coal mines, to reduce the hours of children worked in mills, and to improve housing conditions and the care offered to people with mental illness. Evangelical social reformers and philanthopists in Britain helped ameliorate some of the worst social ills of the Industrial revolution; indeed the nineteenth century has been called ‘the Evangelical Century.’ However, other issues remained unaddressed, and the biggest social reform provisions such as universal pensions and unemployment pay had to wait until government intervention at the start of the new century.”

*See “Christianity: The Biography — 2000 Years of Global History” by Ian J Shaw (Zondervan 2016)

Traveling Wise in a Fast World

Here are some lessons that most of us would benefit from. The only problem is that we may not be able to divide our day into ‘thirds,’ and only work two of three. Medical ministry is pretty demanding. Or should we be thinking differently about healthcare ministry in a mission setting? How can we best communicate Jesus to our patients and staff?

Tending Scattered Wool

Several weeks ago I posted a link to a video that has garnered some good feedback in many circles. You can see the blog here with a link to the video in it.

One person commented on that video post wondering what it would look like to seek to live this type of pace while traveling internationally at jet speed. This is a great question.

Lessons on Itinerant Shepherding
Personal, on-site interaction is a core philosophy of my shepherding. I want to walk the IMG_7018streets of those I tend to – meet their community, sit in their living room (if they want that) – enter into the very fabric of their lives. We all long to be known. Long-term, particularized care leads to others being known, loved and that creates space for life change.

There are some hidden temptations that come with such a model. One of the greatest is…

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What should characterize public health done by Christians?

Public health skills are powerful tools to promote flourishing of communities; they complement medical care of individuals.  Christians also want to promote human flourishing, since this demonstrates the goodness of God.  What will characterize public health done by Christians?

Some of the ancients were inclined to treat disease and plagues in terms of supernatural forces and magic, shamanism and religious practices. The Hebrews stressed regulation of personal and community hygiene, isolation of lepers and other ‘unclean conditions,’ and family and personal sexual purity; God gave to Moses commands related to a weekly day of rest, limits on slavery and oppression, sanitation and food regulations.  The children of Israel gave to the world the teaching concerning human dignity since all are made in the image of God.

Modern public health is a noble sphere of human endeavor, whether done by Christians, Muslims or Secular modernists. Good public health practice should be characterized not only by good science but love for humankind. Christians are especially motivated by the value of human beings, as well as God’s command to love the Lord our God with all our heart, and love our neighbor as ourselves. We glorify God by seeking His best for our fellow human beings.

At the same time, modern public health – Jenner and vaccination, Snow on cholera, germ theory, bacteriologic revolution, hospital reform, immunology, the development of epidemiology – has grown up as part of the modern scientific revolution and out of Enlightenment thinking.  It is often characterized by a ‘split’ of sacred and secular, and a peculiar perspective that things ‘scientific’ define reality whereas things of God are confined to personal and private belief. I believe this is an inadequate foundation for public health as it tends to relegate ethical and moral matters to a private and subjective world.

As Christians we have much we can learn from our public health teachers, and much to give in order to alleviate the suffering of this world.  But ultimately our motivation for doing public health is to demonstrate the character of Jesus Christ to the world; we cannot bring utopia to this world but we can point to a Savior who cares about men and women – body and spirit. He is the Savior who not only frees us from our sinful selves but also frees us for His purposes in a world which He has made and is in the process of re-creating.

As a Christian epidemiologist, I will use the techniques of case control studies, disease surveillance and risk identification just the same as anyone else. The tools are the same, whatever our faith orientation. Our desired outcome – disease prevention and health promotion – will be the same; public health professionals seek the best for others.  Christian public health is not just public health done by Christians; it becomes activities, programs, policy and advocacy informed by God’s Word – which commands us to ‘love justice, seek mercy, and walk humbly with.. God.” (Micah 6:8)

A Christian perspective on public health and human flourishing will be informed not only by material success, but also by an understanding of the darker forces we face, including suffering and death. It will seek to address these matters with courage and meaning. A Christian perspective on public health can deal with life well because of the hope God offers in His promises in both life and death. The cross of Jesus Christ has won the victory of sin, darkness and rebellion in order to usher in life here and eternally.

Ultimately health is not an achievement of man but a blessing of God. And He is working in the world to bless the world through His Son Jesus Christ, who gave His own life for the ultimate in public health – salvation from sin, rescue from darkness and oppression, and the freedom of a life of love and grace.

Why should public health be part of our Christian commitment to mission? Isn’t curative care enough?

There are a great many ways that public health skills are being used in preventive and community health programs around the world. Yet when we think of ‘medical missions’ over the last 200 years there has been a strong clinical (medical) approach.  Why should a preventive approach complement this strong medical component of medical missions?

If diseases all responded to a curative approach, there might not be a need for disease prevention. But in almost any category of “disease,” there is need for BOTH a curative and a  preventive approach.  This can be illustrated with just an example or two.

Neonatal tetanus must be dealt with by antitoxin and medication to avert death and respiratory paralysis, and yet it can be prevented by careful care of the umbilical cord at birth. In one animistic tribe in Ethiopia there was the belief that the umbilicus must be covered with dirt from the entrance of the house in order to control access to the spirits to the entrance of the body; clearly there was a need for both medical intervention for the sick but also for education – addressing not only the biology but also the fear of spirits which were part of the local worldview.

In Nepal there is a high maternal mortality rate because of lack of access to facilities with good midwifery and caesarian section capability. The problem cannot be addressed with clinical care alone, but there must be attention to community education, early detection of high risk pregnancies, and training of community based midwives.

Ebola needed both treatment units (highly intensive and technical) as well as community education and contact tracing – both a highly clinical approach to the individual as well as a highly preventive approach in the community.

Road traffic accidents must be treated with competent facilities and personnel, but to reduce the incidence of accidents also requires community and government initiative, safe roads, helmets, seat belts, and a shift in mindset away from fatalism.

Almost every condition requires both a clinical and non-clinical approach. Physicians and nurses are superb at what they do, but there is much that remains undone, either in prevention of illness and injury, or in follow up management of those with chronic conditions, infections and disabilities.

God’s covenant promise to Abraham was to bless all the nations of the earth through him and through his descendants. God showed his concern for justice and human flourishing as he gave to his descendants the commands, promises and laws which reflect the best of human flourishing. Jesus – the descendant of Abraham – continued to show God’s character by healing many and sending his disciples out preach good news and to heal many others. The compassion of Jesus has led many over the centuries to sacrifice their own comfort out of compassion for others.

Is God concerned with prevention of human suffering? Does He encourage us to promote health as well as cure disease?  Yes!  God’s Word stands in contrast to the thinking of behaviorists or other forms of fatalism – those who believe we can’t really change things.  We are not able to manipulate the universe but God does sovereignly control the world and works out all things according to His purposes and design.  He has demonstrated His promised blessing to Abraham and His children, and ultimately in the person of Jesus Christ.  This is a universe created and sustained by a Person – good, righteous and true — not an impersonal force.

A Christian can confidently work to show God’s care for human life. As followers of Jesus Christ we trust that the Lord of the universe can change things (He has authority and power) and that He (not we) ultimately works for the blessing of mankind. The salvation Jesus accomplished on the cross bridges the sin problem (our separation from God) and thus enables us, by His grace, to both love God and love our neighbor. That love extends not only to care but to the prevention of human misery.  That’s public health from a Christian point of view.