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.

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.

A new era in Roman healthcare

We take for granted that compassion is a natural response to the suffering of those who are ill. But compassion was not well-developed as a virtue in Roman culture.  Rome had not developed a culture of compassion; “mercy was discouraged, as it only helped those too weak to contribute to society.” Family members may come to one’s aid, and the wealthy could afford physicians, but “the common folk were often left to rely on folk healers and sellers of herbs, amulets and quack remedies.” *

“If a father decided that the family couldn’t afford another child, that child would be abandoned to the steps of a temple or in the public square. Female infants were exposed much more often than males.” These attitudes and practices are still with us today.  In India and China the practice of aborting female offspring is distressingly common.  In many parts of the world the handicapped are treated with disdain or neglect.

“The classic world possessed no religious or philosophical basis for the concept of the divine dignity of human persons, and without such support, the right to live was granted or withheld by family or society almost at a whim.”

What made the difference between attitudes then and now?  At least in many parts of the world today, human rights and dignity are considered absolutely fundamental (and they are!). Where then did these more ‘progressive’ beliefs come from?  The new ‘era’ in Roman healthcare came from the least likely place: from a new, small and persecuted culture which penetrated the classic Roman world: the culture of the Christians.

Despite a series of ten devastating persecutions, beginning with Nero in AD 64, Christians “carried on an active ministry of philanthropy which included the care of the sick. Far from the stereotype of shriveled ascetics who hated the body, early Christians valued the body and the medical arts necessary to heal it as good gifts from God.”

“James defines “religion that is pure and undefiled before God” in part as caring for ‘orphans and widows’ (James 1:27) — biblical shorthand for all those without protectors and in need. Christian theology thus birthed a personal and corporate charity which surpassing any previously known. Church leadership encouraged all Christians to visit the sick and help the poor, and each congregation also established an organized ministry of mercy.”

How different this is from our practices today!  How often we are concerned about ourselves without hearing the Lord’s commands to love God with all our heart and our neighbors as ourselves.

“A devastating epidemic began in 250 AD and spread across northern Africa to the Western Empire.  It lasted 15 to 20 years, and at one point in Rome 5,000 people died in one day. Beyond offering supplications to the gods for relief, public officials did nothing to prevent the spread of the disease, treat the sick, or bury the dead. This is not surprising, since the pagans believed that nothing effective could be done in a time of plague other than appeasing the gods.”  However in places like Carthage, north Africa, where the plague swept in with force, the Bishop Cyprian  “encouraged Christians to donate funds and volunteer their service for relief efforts, making no distinction between believers and pagans.”  They continued these organized emergency relief efforts for five years.

“The ministry of medical care in early Christianity began as a church-based diaconal, not a professional, ministry.  It was provided by unskilled, ordinary people with no medical training. Yet the church created in the first two centuries of its existence the only organization in the Roman world that systematically cared for its destitute sick.”

This is not a secret we want to keep from believers around the world today.  From Syria to Thailand, believers are caring for those who are marginalized and ill.  But sometimes I fear we forget our history, and we forget God’s command to love our neighbor.  Medical missions are a wonderful calling and ministry. But as we go about it we must not ‘overly professionalize’ ministry to those who are sick and brokenhearted. Unskilled believers ushered in a new era of healthcare in the Roman empire.  We have the opportunity to do the same among multiplied countries around the world, demonstrating goodness and grace of God, and the dignity of men and women created in His image.  This can be done only as professionals work together with non-medical professionals to care for the needs around them, especially those who are least able to help themselves.

Despite the cost, let’s help usher in a new era of healthcare around the world.

*Quotations are from “Christian History, Healthcare and Hospitals in the mission of the church,” Issue 101, pages 6-12

Taking it in steps?

A missionary doctor, nurse or health provider in his or her first term is all enthusiasm. After all, he or she may think, “After all that preparation, let’s get on with the real work!”

But those first few years show how much more there is to learn! First there is the adjustment to the new sights and sounds, then a new set of co-workers, then a new job, and of course there is langauge learning!  We want to provide excellent medical care but face the obstacles that often exist in resource-poor settings.

On top of these things, in those first years we may also be working on:

  • issues of marriage and singleness
  • growing a family
  • integrating spiritual and physical ministry into practice
  • understanding how our role fits with the vision and strategy of mission and church
  • doing things outside of his or her training, such as leading a team or projects
  • conflict and team formation
  • identity issues (“who am I really?”)

During this intense time of learning and growing, sometimes I am asked for advice on getting futher training: should I do an MPH degree?  get tropical medicine? learn more about management and leadership?

Looking back over my own 30 years with SIM in medical missions, I think I tried to do too much too early. So my suggestion is this: take a longer view and then break it up into steps.

The complexity of the task means that if we try too much too soon, we won’t do anything well. So in the early years it may be best to focus on the basics: our relationships, especially marriage/singleness/family; language learning; and practicing what we have been trained to do.

Then it will become clear what is needed for later stages.  Not everyone needs to go on and do a public health degree.  Not everyone needs to go to seminary.  Not everyone needs to become skilled in management.  But everyone should grow in their understading of their gifts and abilities, and over time, take on new challenges. Everyone should grow in grace and the knowledge of our Lord Jesus Christ.

“For we are His workmanship, created in Christ Jesus for good works, which God prepared beforehand that we should walk in them.” (Eph 2:10).

The process of discovering those good works prepared for us by God is a journey.

Let’s take it one step at a time.

 

Too much to do? Time to re-examine our own assumptions!

Stress and burnout are recognized themes in medical missions.  One source of stress is the sheer magnitude of physical needs; one billion people in our world have no access to a trained health worker and healthcare workers often stand in the gap.

In the face of overwhelming need how do we maintain healthy margins?  Overextended, we lose our compassion, damage relationships, and often leave our fields of service early.  Yet, the pressure is there, since the patients show up, the children are literally dying, and there is often no alternative for those who are the most marginalized.  Wouldn’t Jesus have compassion on the sick and dying?

In the late 1980s I was in a similar situation in southern Ethiopia, where I was called to lead a small team to treat patients dying among the Mursi tribe; hundreds were dying around us from meningococcal meningitis.  While we had some effective antibiotics we couldn’t get ahead of the need – patients were dying faster than we could treat them.  In our case, the answer was not so difficult, as the Ethiopian ministry of health asked us to bring along their workers and meningitis vaccine; thus we were both able to save many who were ill, but also prevent new cases with vaccine.  Caring for the ill and prevention went hand in hand – with a team approach.

But what about a hospital or clinic where the people come each day and yet the facility and staff are still overwhelmed?

One approach has been to assign numbers to non-emergency patients to limit those who can be seen on a given day.  Other barriers have been erected, such as raising fees – although this limits care to those who are most vulnerable and thus tends to defeat our purpose.  Outpatient clinic hours can be trimmed.  Specialty clinics can be opened only certain days.  All these efforts are ways of establishing boundaries and limits.  Some are needed; some are painful.

Yet, our hearts as medical providers are driven by compassion; we want to see as many as possible.  Compassion is from the Lord, and our instincts may be noble. But unexamined assumptions may contribute to our own burnout and long term lack of fruitfulness.

As medical healthcare workers and missionaries, do we recognize our own limits and vulnerabilities?  Or are we driven by a “Savior” complex where we must be the answer to everyone’s need?  Do we allow the needs to constitute our call, or does Jesus Christ shape the call?  If we are called and empowered by Him (as the true vine) then we (as his branches) can only produce eternal fruit as we allow Him to work through us.  Yes, this kind of ministry can be overwhelming, even impossible.  Are we connected to Him as the vine well enough that the life-giving grace of God gives us wisdom and strength?  Or have we subtly become “the vine” ourselves in the midst of the needs?

We do want to give our lives for others.  Good.  But our own wisdom and strength quickly fades and we must come to Christ and His word.  We might have the desire to “burn out for Jesus” but taken to the extreme we will damage our family and other relationships.  Exhaustion and callousness on a chronic basis are not the ‘living stream of water’ that Jesus promised would come from our hearts!

What is our ultimate purpose in medical missions?  It is to glorify Jesus Christ.  We become like a seed which falls into the ground; it must die and spring up with new life.  My hospital, my program, my health teaching – these are all means God uses to show His character through suffering and healing, to make disciples, to enable others to connect to the vine – ultimately serving others by God’s grace.

We must reflect on this ‘Me-first’ mentality.  Do we assume that these health ministries are about us and our ability?  That’s a prescription for the prosperity gospel!  Let’s not promote a false gospel based on our works rather than grace.

The ultimate purpose is to establish God’s reign, God’s kingdom on earth – or some small signpost of the kingdom in a broken and twisted world. We can make a real difference. However it is not by our trying hard enough, but by abiding in the Vine. We don’t want to plant our program; we want to plant the mission of Jesus.

Health is not just about the physical needs of those who come to us, but about their social, economic and relational needs. I fear that too often we apply a Western mindset [think separation of physical from spiritual/non-physical reality].  One way of creating more helpful margins is to actually involve local staff and others from churches and community in the care of those who come to us – enabling them to connect with our programs as whole people, not just disease conditions.

This takes building leadership for healthcare missions, not just adding medical practitioners.

Eventually this means we work with local doctors, community, nurses, churches, believers – to build healing communities. Only through teamwork can we begin to meet the overwhelming needs of those around us in a deeper way.  And yet in this way – as we die to our own ambitions – we are enabling others to see and to know and to serve the Lord Jesus Christ.  He is the King and Savior and healer and He is building His kingdom. We get the privilege to be a small part of His work. He is worthy!

Navigating a path to sustainable Chinese medical mission participation

Take a look at some the challenges that Chinese Christian doctors could face as they consider God’s call to missions. And this article doesn’t even begin to address the cross-cultural issues of Eastern and Western medical worldviews!

As you consider these hurdles, let’s not think ‘it can’t be done!’ Rather, let’s think that “God is the God of the impossible.”  How might God move us as Western mission workers to include and partner with missionaries from other cultures.  Not so much to use them for ‘our’ work but to bless them for the sake of the Kingdom of God.

At the same time let us use our resources not just to do ‘our’ work but to develop spiritual leadership for medical missions which is diverse — celebrating and demonstrating the Kingdom of Jesus.

Challenges?  Yes. Opportunities? Definitely.  Needed? Leadership. Why?  Because this reflects the character of God and reflects His glory.

Jesus taught us, “With God all things are possible.”  Matthew 19:26