Cover image courtesy of Project HOPE.
Written by Sophia Mitra, The University of Oklahoma
This article examines the organization Project HOPE and explores concerns regarding its use of international healthcare volunteers as well as its contribution to the long-term improvement of the healthcare system in Sierra Leone.
Abstract
Project HOPE claims to place “power in the hands of local health care workers to save lives across the globe” through the work of dedicated medical volunteers. In Sierra Leone, one of the poorest countries in the world, Project HOPE works to address maternal, neonatal, and child health outcomes within a barely functioning health system. International healthcare volunteer programs like Project HOPE have the capability to save lives and improve communities. However, there are ethical concerns surrounding this form of volunteering, often called medical voluntourism. Motivations of the volunteers tend to be self-serving with themselves being the beneficiaries. There is also a tendency for volunteers to complete their short-term assignments without any prior knowledge of the host country and its history, culture, or healthcare systems. This raises the question of whether volunteers can properly provide training within a local context. In addition, volunteers often approach their work from a deeply rooted position of superiority that prevents collaboration. Along with these concerns about volunteer work, there are concerns about the programs that they work for. Project HOPE claims to be strengthening Sierra Leone’s health system, but it is not addressing some of the main issues preventing the current health system from functioning well. This leads to the question of whether the organization can truly promote long-term improvement. This article will explore these concerns and outline ways they might be addressed.
Introduction
Project HOPE is an organization that sends volunteers to Sierra Leone, where there is a lack of healthcare access and severe mother and infant mortality rates, in hopes of strengthening health systems to improve health outcomes. The organization’s motto is “healing people, transforming lives” [1]. While they may be healing people and transforming lives, it is not clear whether their use of short-term, insufficiently trained volunteers and their approach to addressing health disparities is an ethical or effective solution in the long term.
Overview of Sierra Leone and Project HOPE
Sierra Leone, located in West Africa, is a country with tropical landscapes and abundant mineral resources. It is also one of the poorest countries in the world, stricken by political instability and conflict, the 2014 Ebola epidemic, and natural disasters all within the past couple of decades. Around sixty percent of the population lives below the national poverty line, and from a health standpoint, “Sierra Leone is one of the most dangerous places to live” [2].
Sierra Leone’s lack of health infrastructure was weakened further by the two-year epidemic of Ebola that arrived in 2014. This epidemic killed twenty-one percent of their healthcare workforce, and in 2015, it was recorded that 245 doctors were left to serve over 7 million people [2]. A shortage of healthcare workers, medicine, and healthcare facilities combined with a largely rural population has led to limited healthcare access for the majority of people in Sierra Leone. This is seen especially in the prevalence of maternal and infant mortality. Sierra Leone has the highest maternal mortality rate in the world at 1,120 deaths per 100,000 live births, “a rate six times higher than the global average.” This means one in seventeen women die during delivery. Sierra Leone also has one of the highest infant mortality rates, found to be 81 deaths per 1,000 live births [3].
High mortality rates along with poverty, lack of clean water and food, and lack of access to healthcare illustrate a drastic need for improved health in Sierra Leone. This need is what caught the attention of the international, global health, and humanitarian relief NGO, Project HOPE (Health Opportunities for People Everywhere). Project HOPE began in 1958 as a peacetime hospital ship called the SS Hope which traveled to help vulnerable communities in other countries. The organization has since become land-based and focuses on various areas of public health to “[place] power in the hands of local health care workers to save lives across the globe” [1]. Project HOPE originally began work in Sierra Leone in response to the 2014 Ebola outbreak, but it has since created programs to train local healthcare workers and improve maternal and neonatal health.
One Project HOPE training program promotes Kangaroo Mother Care. The NGO started two Kangaroo Mother Care units in Ola During Children’s Hospital and Bo District Hospital in Sierra Leone. Kangaroo Mother Care is a low-cost, low-technology intervention technique where premature and low birth weight babies are exposed to continuous skin-to-skin contact with their mother. Project HOPE promotes this method in these hospitals because they usually do not have incubators to provide thermal care [4]. Theresa Massaquoi, a mother of baby Augustine who was born at seven months and stayed in a Kangaroo Mother Care Unit, states Project HOPE is “giving hope to the hopeless” [5]. Project HOPE also helps support neonatal unit renovations and learning labs for healthcare workers. The organization trains healthcare workers who then train mothers how to feed premature and low birth weight babies, techniques to prevent infections, and how to help babies that are having trouble breathing. By teaching mothers how to care for their own babies, “HOPE’s footprint extends beyond hospital walls into the villages where the most vulnerable women and children live” [2].
To further this “footprint” of spreading knowledge, Project HOPE helps facilitate mother care support groups. These are groups of around twenty mothers that are led by a lead mother who is trained first by Project HOPE. In the groups, mothers learn lessons on recognizing health issues, how to properly breastfeed, and how to ensure proper hygiene and care following birth. Since the majority of mothers are not literate, these lessons are typically taught through illustrations, dancing, or singing. Project HOPE also uses lead mothers to advocate for regular health checkups during pregnancy and hospital births over home births. This has even led the Sierra Leone government to distribute fines to mothers who decide to give birth at home. Overall, the mother care support groups have “become a celebration of motherhood and sisterhood, of their solidarity and shared commitment to improving the lives of their families” according to Bannah Daremy, a Project HOPE newborn consultant pictured at the top of this article. Baindu Mansaray, one lead mother, claims “there are many [people] who come to help. But the most valuable has been Project HOPE” [6]. It is clear that mother care groups are valued by those involved in them.
Another component of the mother care support groups Project HOPE has implemented is a Village Savings and Loan (VSL) Program. This is a program where mothers learn how to manage their finances and then receive loans to “improve autonomy and security.” Loans are commonly taken out by mothers to receive emergency medical treatment for their babies if needed [5]. Thus, Project HOPE helps mothers gain independence over the health of their children. They do not make it clear on their website how these loans work though, so for the most part, this article will address their healthcare programs.
There is no doubt that Project HOPE’s Kangaroo Mother Care Units and mother care support groups have helped save many mothers and newborn infants’ lives and have helped improve maternal and neonatal health in Sierra Leone. Nonetheless, it is important to consider possible implications of Project HOPE’s volunteer approach and to question whether their programs are actually promoting long-term development for Sierra Leone’s healthcare system.
The Volunteer Approach
Project HOPE largely depends on the work of their medical volunteers who they claim are the “key” to their work and are “central to [their] mission” [7]. This is an example of international medical volunteering where medical professionals from different specialties go overseas to a foreign country, often deemed as “low income”, to provide medical services and help improve health outcomes. This type of work is also often described as “medical voluntourism.” These are often short-term volunteer positions, and Project HOPE offers assignments as short as two weeks [7]. Short-term medical voluntourism is frequently associated with several negative aspects including questionable motivations of volunteers, a lack of proper training and preparation of volunteers, and power differentials. These concerns relate to Project HOPE’s volunteer approach.
Project HOPE may claim that its primary motivation is to save lives through its work. Yet, the underlying motivations of its volunteers appear to be self-serving. On the volunteer page of its website, the NGO lists “Benefits of Volunteering with HOPE” that include growing one’s professional network and career, increasing cultural competence, finding a sense of purpose in life that can put circumstances into perspective, getting recognized by Project HOPE following one’s service for going “above and beyond”, and enjoying the benefits of being a part of Project HOPE’s Alumni Association. The page also quotes Fidel Reyes who volunteered in Puerto Rico for the organization and claimed it to be an “enriching experience” where he “felt how rewarding it was to give a hand” [7]. It is clear that none of these benefits mention anything about the people that are supposedly receiving the help of Project HOPE. These motivations are all focused on the benefits of volunteering for the medical professionals themselves. This produces an ethical concern about whether Project HOPE’s volunteers are truly working to improve health outcomes or if they want to expand their professional network and career opportunities while enriching their egos.
These motivations have been extensively studied and revealed in the medical voluntourism sector of aid. In studying international clinical volunteers working in low-income countries through volunteer placement organizations, Noelle Sullivan found that short-term volunteer trips often benefitted the volunteers more than host communities. Her study focused mainly on pre-medical students who took the opportunity to perform procedures and surgeries they would not be able to perform in the U.S. and to increase their chances of being admitted to medical school [8]. Although Project HOPE only uses volunteers with professional degrees, there is a similarity in the emphasis on egoistic motives.
Hannah Sullivan also explores the ethical implications of international medical volunteering, and based on reports of British physician experiences in traveling to train Nepalese health care workers, concluded that “they tend to focus more on the benefits to themselves than to the people they are putatively helping.” Liisa Malkki who did ethnographic research on Finnish Red Cross international aid workers found a variety of motives related to the self including being a part of occupational solidarities, a desire to travel, wanting to leave home and escape the bores of everyday life, or even to gain sensual experiences [9]. All of these findings in these studies seem to align with the conclusion drawn from Project HOPE’s website that many of the motivations that international healthcare volunteers claim are self-centered. The question is then who is actually being helped in this whole experience. In a similar evaluation of surgeons going on international volunteering trips, researchers found seven areas of concern, listed as “seven sins of humanitarian medicine”, including “doing the right thing for the wrong reason” [10]. Project HOPE volunteers appear to be volunteering more to help themselves than to help those in Sierra Leone. These self-serving motives are problematic because they contradict the organization’s goal to save lives as the volunteers show less concern for those lives being “saved” than their own benefit.
Another issue with Project HOPE’s volunteer approach is that there usually is not enough training and preparation of the volunteers before their departure. This often leads to a lack of historical knowledge, cultural incompetence, and clinical unpreparedness. On their website, Project HOPE claims that their volunteers are “equipped with expectations, detailed scope of work, and regular communication with [their] local in-country staff and partners prior to their service.” They then provide a Volunteer Checklist that lists everything a volunteer must do. After a volunteer’s application is accepted, all that is required before departure is a Skype meeting with a field office, a physical exam, and a pre-departure orientation to review expectations. During the Skype meeting, there is an introduction of the program’s needs, the scope of work, and travel logistics [7]. None of the checklist points reveal requirements for training in history or culture. Therefore, Project HOPE either acts on the assumption that knowing the history and culture of a country are irrelevant to providing medical care to local communities in that country, that it would be too much work or it would take too long to educate volunteers, or that volunteers should take it upon themselves to learn about the countries they are going to. However, this should be a prerequisite to participation.
These issues with volunteer training were exhibited in a study done on another Project HOPE program in Ghana where, similarly, short-term volunteer medical professionals were sent to Ghana to train emergency medicine residents. The study revealed that there was no formal orientation program for the volunteers, and they were often expected to teach physicians, nurses, and even surgeons without being familiar with cultural or clinical contexts. Another issue noted was that volunteers had different training needs which made it difficult to create a “one size fits all” program [11]. The reality is that cultural and clinical context is needed in order to properly train local medical professionals, and even if some volunteers know more than others, they likely still need some sort of training. This is likely the case with Project HOPE’s Sierra Leone volunteers.
There is another study that was done on short-term volunteer health trips that focused on comparing practices of over 300 organizations with their in-country host community preferences. It was found that the majority of the organizations provided their volunteers with information packets containing information about traveling, packing, and required shots while only some provided reading materials on the country being visited or had an in-person orientation program. Host community staff indicated that there needed to be more preparation before arrival in language, culture, the projects being carried out, and country conditions. One Nigerian employee suggested the need for information on “the physical and spiritual healing of children” while other employees mentioned that volunteers need to know the environment the patients seeking treatment live in [12]. There should be training or orientation in place to make sure volunteers are culturally and socially competent to provide care within the local setting. Without being able to adjust the pathway of care to account for living environments and cultural understandings of medicine it is unlikely that international volunteers will be able to carry out proper medical care for their patients or train others to do so. Preparation in language, culture, and country condition or history are not part of Project HOPE’s preparation of their volunteers for Sierra Leone. Not everyone in Sierra Leone speaks English, and as discussed in the Overview, the country has gone through many recent political and social issues that are important for volunteers to fully understand. Therefore, improvements in training are needed.
In addition to concern about volunteer preparation, there needs to be a concern about the power differential that results when volunteers go into a country thinking they are inherently superior to local medical professionals and communities. Dr. Tom Kenyon, Project HOPE’s Chief Health Officer explains the importance of working with local counterparts to “figure out the local vision and how [to be] of help to that vision” [13]. These power differentials fundamentally undermine that collaboration, placing the volunteers’ needs and visions over those of local communities. Behind the power differential lies the “white savior industrial complex” where “predominantly white and privileged groups assume they can ‘make a difference’ without understanding the complexities of context of those being ‘helped’” [8]. Additionally, international volunteering has “neocolonial echoes” that enable volunteers to conceptualize themselves as part of “real medicine”, helping the “resource-poor” [8]. Medical voluntourism is also often described as a “charity-based approach” based on a “good Samaritan” concept where volunteers provide resources and knowledge to vulnerable people rather than instituting equal collaboration [14]. Whether related to the white savior complex, imperialism, or charity, short-term medical volunteer programs like Project HOPE Sierra Leone are rooted in inequality.
Prior assumptions and inequality lead to limited collaboration, which can work against local health strategies instead of supporting them [9]. The power differential is much broader than volunteers though, and it extends to Project HOPE itself. Organizations control financial and educational resources which leads to an attitude of superiority [12]. This means that organizations like Project HOPE usually control the outcomes of their work, not always to the benefit of the “low-income” country. The next section of the article explores the long-term impact of Project HOPE’s Sierra Leone program.
Promoting Long-Term Development?
Project HOPE’s Sierra Leone programs are only band-aid solutions in that they do not address many of the root problems that are causing health problems in the country and often perpetuate reliance. This deems it unlikely that the program could promote long-term development as stated in its goals [1]. Sierra Leone’s issues with healthcare system corruption and fragmentation of government and funding lead to a reliance on external engagement with organizations like Project HOPE that, in turn, prevent the independence of local health care and ignore pre-existing relationships in the country between the local community and international aid workers.
Corruption within the healthcare system provides an additional barrier to healthcare access for a large portion of people in Sierra Leone. An Afrobarometer survey of adults in Sierra Leone revealed that more than half said medical care was difficult to obtain because they had to “pay a bribe, give a gift, or do a favour.” Furthermore, the likelihood of having to pay a bribe to receive medical care increased for poor, less-educated, or older citizens [15]. These groups of people are not only the most vulnerable healthwise, but are also the groups least likely to be able to pay for their bribes and medical care. Project HOPE’s advocacy for pregnancy visits and in-hospital births is highly complicated by this corruption, yet they do not address this issue. Furthermore, their support of the government to impose fines on mothers who give birth at home only perpetuates these inequalities.
Not only is Sierra Leone’s healthcare sector corrupted, but it is highly fragmented. Sierra Leone has received International Monetary Fund (IMF) support for over two decades. In exchange for these loans, state budgets have been decreased, public services have been privatized, and government systems have been decentralized to encourage foreign investment [8]. This leads to a health sector under the Ministry of Health but also leads to a need for other health systems operated under external NGOs like Project HOPE. The reliance on external assistance prevents the development of health systems [16]. In other words, reliance on programs like Project HOPE prevents the strengthening of Sierra Leone’s domestic health sector and ensures continued reliance on the same programs. This failure to foster self-sufficiency is another criticism of international medical volunteering introduced by Hannah Sullivan who explains that when a volunteer program like Project HOPE “supplants a local health system instead of supporting it”, it may cause what little infrastructure is already present to erode because people would prefer the free health care from volunteers and the programs that bring them [9]. This is where Project HOPE’s “footprint” out in the villages and communities may be helpful to create a community that has more knowledge about maintaining health, but still, there is the concern that the organization is not truly promoting long-term development. The ultimate goal should be for there to be a fully functioning healthcare system where there is no need for receiving help from outside organizations like Project HOPE.
Another obstacle to long-term development that Project HOPE does not mention addressing is a widespread, pre-existing apprehension toward international medical aid workers that remained in Sierra Leone after the 2014 Ebola epidemic. When the epidemic broke out, the community in Sierra Leone had little trust in the international aid workers that came to help. There were rumors that doctors were “mining” blood and that the government was killing people for its own financial benefit, beliefs that likely resulted from past colonial violence and government corruption. There was also distrust that resulted from the contradiction of the large response to Ebola and the usual lack of assistance for other common diseases in Africa. Other social apprehension was a consequence of the disregard international aid workers displayed for burial rituals and other social aspects of life common in Sierra Leone when creating public health regulations. The fears of Ebola may have gone away with the epidemic, but research shows that a general skepticism toward healthcare and international medical aid has not [17]. This skepticism is also reiterated by the section chief of Mathiane, Sierra Leone, who explains a lack of assistance following Ebola has left them wondering “who cares about us now?” [18]. This fear and skepticism leftover from the lack of continued care after the Ebola epidemic threatens acceptance of help from organizations like Project HOPE and the development of a functioning health system in Sierra Leone.
Richards argues that it is crucial for international NGOs to show they are “genuinely concerned with improving the long-term health situation of populations” if they are to minimize skepticism towards health care within Sierra Leone. As discussed above, Project HOPE does little to promote long-term development by creating dependency on itself, and thus, it can be assumed that the NGO is doing little to address the long-lasting skepticism towards healthcare workers in the country. This combines with the failure to address corruption and fragmentation within the system to illustrate that Project HOPE neglects many of the underlying causes of poor health in Sierra Leone.
Conclusion
Project HOPE appears to oversimplify its impact in Sierra Leone. While the NGO is providing knowledge and support to healthcare workers, mothers, and infants, its volunteer approach threatens informed and equal collaboration with local communities, and its disregard of other barriers to a functioning health system impedes any long-term development. Still, there are ways to minimize the negative impact.
To modify the volunteer approach, Project HOPE should encourage some sort of self-assessment. Volunteers may check their motivations and make sure that they are doing the work for more altruistic reasons that align with the organization’s mission statement rather than self-serving ones. Project HOPE could also rewrite the benefits of their work and goals to be less volunteer-based and more community-based. Volunteers should be required to undergo or exhibit more in-depth training on language, culture, country history and conditions, and factors affecting the efficacy of healthcare systems. To support this increase in training there would likely be a need for longer volunteer assignments. Just as importantly, volunteers must be educated on prior assumptions of superiority, and Project HOPE should foster more equal collaboration by putting less emphasis on what volunteers can “give” to Sierra Leone and more emphasis on how they can work with the local community to improve health outcomes.
Additionally, there needs to be an adjustment of the program to include a plan for the eventual establishment of self-sufficient healthcare in Sierra Leone. While it would be difficult for the organization to address corruption and fragmentation in the health system directly, acknowledging the two issues would be helpful. The organization could also increase efforts to create more independence in local healthcare. The goal, supposedly, is to eliminate Sierra Leone’s dependency on Project HOPE. This would mean supporting domestic sufficiency in the training of healthcare workers and medical supplies. By making a plan for long-term development, Project HOPE could also decrease skepticism towards healthcare in the wider, local community. Since there would be a need for local reforms too, Project HOPE must acknowledge that the obstacles to a working health system in Sierra Leone are complicated and should refrain from the idea that by sending volunteers to the country, they can ultimately “fix” the problem. Overall, the NGO should focus on how to minimize harmful impacts to truly help advance maternal, neonatal, and child health in Sierra Leone in the most effective way.
This post may have been edited by admin for clarity and length.
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[1] Project HOPE About Us. Project HOPE, 2021, https://www.projecthope.org/about-us/. Accessed 3 May 2021.
[2] Project HOPE Sierra Leone. Project HOPE, 2021, www.projecthope.org/country/sierra-leone/. Accessed 18 April 2021.
[3] Unicef Sierra Leone Statistics. Unicef, 2021, https://data.unicef.org/country/sle/. Accessed 12 May 2021.
[4] “Webinar: Advancing Neonatal Nursing Education in LMIC in Africa.” Youtube, uploaded by Project HOPE, 24 June 2020, https://www.youtube.com/watch?v=eM27ErMDHLE.
[5] Schwartz, Emma. Giving HOPE to the Hopeless: Snapshots from Sierra Leone. Project HOPE, 2019, https://www.projecthope.org/giving-hope-to-the-hopeless-snapshots-from-sierra-leone/11/2019/. Accessed 4 May 2021.
[6] Schwartz, Emma. Health Care Worker Spotlight: Reaching Mothers and Babies in Sierra Leone. Project HOPE, 2021, https://www.projecthope.org/health-worker-spotlight-reaching-mothers-and-babies-in-sierra-leone/11/2019/. Accessed 18 April 2021.
[7] Project HOPE Volunteer. Project HOPE, 2021, https://www.projecthope.org/volunteer/, Accessed 18 April 2021.
[8] Sullivan, Noelle. “International clinical volunteering in Tanzania: A postcolonial analysis of a Global Health business.” Global Public Health, vol. 13, no. 3, 2018, doi: 10.1080/17441692.2017.1346695. Accessed 4 May 2021.
[9] Sullivan, Hannah. “Voluntourism.” AMA Journal of Ethics, vol. 29, no. 9, 2010, doi: 10.1001/amajethics.2019.815. Accessed 18 April 2021.
[10] Welling, D., Ryan, J., Burris, D., et al. “Seven Sins of Humanitarian Medicine.” World J Surge, vol. 34, 2010. https://doi.org/10.1007/s00268-009-0373-z. Accessed 4 May 2021.
[11] Rominski, S.D., Yakubu, J., Oteng, R.A. et. al. “The role of short-term volunteers in a global health capacity building effort: the Project HOPE-GEMC experience.” International Journal of Emergency Medicine, vol. 8, no. 23, 21 July 2015. https://doi.org/10.1186/s12245-015-0071-6. Accessed 18 April 2021.
[12] Rozier, M., Lasker, J., and Compton, B. “Short-term volunteer health trips: aligning host community preferences and organizer practices.” Global Health Action, 2019. https://doi-org.ezproxy.lib.ou.edu/10.1080/16549716.2017.1267957. Accessed 18 April 2021.
[13] Kenyon, Tom. “Current Challenges in Global Health.” Youtube, uploaded by Children’s National Hospital, 5 February 2020, https://www.youtube.com/watch?v=P5Y_mUtB470&t=3764s.
[14] Snyder, J., Dharamsi, S., and Crooks, V. “Fly-By medical care: Conceptualizing the global and local social responsibilities of medical tourists and physician voluntourists.” Globalization and Health, vol. 7, pg. 6, 6 April 2011, doi:10.1186/1744-8603-7-6. Accessed 18 April 2021.
[15] Sanny, Josephine. “Sierra Leonians say health care hard to access, beset by corruption – especially for the poor.” AfroBarometer, no. 346, 2020. Accessed 4 May 2021.
[16] Barr, A., Garrett, L., Martin, R., et al. “Health sector fragmentation: three examples from Sierra Leone.” Global Health, vol. 15, no. 8, 22 January 2019. https://doi-org.ezproxy.lib.ou.edu/10.1186/s12992-018-0447-5. Accessed 18 April 2021.
[17] Richards, P., Mokuwa, E., Welmers, P., et al. “Trust, and distrust, of Ebola Treatment Centers: A case study from Sierra Leone.” PLoS One, vol. 14, no. 12, 2 December 20. https://doi.org/10.1371/journal.pone.0224511. Accessed 18 April 2021.
[18] Parker, M. and Allen, T. “#PublicAuthority: What will happen when there is another epidemic? Ebola in Mathiane, Sierra Leone.” Firoz Lalji Centre for Africa, 15 February 2018, blogs.lse.ac.uk/africaatlse/2018/02/15/publicauthority-what-will-happen-when-there-is-another-epidemic-ebola-in-mathiane-sierra-leone/. Accessed 4 May 2021.
