Mantey et al. Globalization and Health          (2021) 17:115 
https://doi.org/10.1186/s12992-021-00741-0
RESEARCH Open Access
Ghanaian views of short-term medical
missions: The pros, the cons, and the
possibilities for improvement
Efua Esaaba Mantey1*, Daniel Doh2, Judith N. Lasker3, Sirry Alang3, Peter Donkor4 and Myron Aldrink5
Abstract
Background: Various governments in Ghana have tried to improve healthcare in the country. Despite these efforts,
meeting health care needs is a growing concern to government and their citizens. Short term medical missions
from other countries are one of the responses to meet the challenges of healthcare delivery in Ghana. This research
aimed to understand Ghanaian perceptions of short-term missions from the narratives of host country staff
involved. The study from which this paper is developed used a qualitative design, which combined a case study
approach and political economy analysis involving in-depth interviews with 28 participants.
Result: Findings show short term medical mission programs in Ghana were largely undertaken in rural
communities to address shortfalls in healthcare provision to these areas. The programs were often delivered free
and were highly appreciated by communities and host institutions. While the contributions of STMM to health
service provision have been noted, there were challenges associated with how they operated. The study found
concerns over language and how volunteers effectively interacted with communities. Other identified challenges
were the extent to which volunteers undermined local expertise, using fraudulent qualifications by some
volunteers, and poor skills and lack of experience leading to wrong diagnoses sometimes. The study found a lack of
awareness of rules requiring the registration of practitioners with national professional regulatory bodies, suggesting
non enforcement of volunteers’ need for local certification.
Conclusion: Short Term Medical Missions appear to contribute to addressing some of the critical gaps in
healthcare delivery. However, there is an urgent need to address the challenges of ineffective utilisation and lack of
oversight of these programs to maximise their benefits.
Keywords: Volunteers, short term medical mission, healthcare
Background government with inadequate resources. Short-term
Many countries in sub-Saharan Africa face the challenge Medical Missions (STMMs) have become one avenue
of providing quality healthcare to their citizens as a for extending healthcare delivery in countries such as
result of limited resources. Successive Ghanaian govern- Ghana.
ments, for example, have worked to increase the Historically in Ghana, large numbers of people have
provision and quality of Ghana’s healthcare delivery. engaged in short term medical missions yearly. They
Irrespective of effort, the challenges remain for a come primarily from High Income Countries (HICs) to
provide medical care for a short period, usually four (4)
weeks or less. These group include doctors, nurses, stu-
* Correspondence: efuam@yahoo.com
1Department of Social Work, University of Ghana, Legon, Ghana dents, and non-medical volunteers. Yet there are no data
Full list of author information is available at the end of the article
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Mantey et al. Globalization and Health          (2021) 17:115 Page 2 of 14
available on the number of groups that arrive each year, possibility of foreign physicians competing with, or even
where they work and what they accomplish. These activ- replacing, locally trained professionals [18].
ities are largely unregulated and unevaluated. It is there- Studies also report satisfaction with the experience of
fore essential to understand their value and the hosting volunteers, including appreciation for the con-
challenges they present. cern shown by visitors for underserved people, the “extra
STMMs, also referred to as Short-term Experiences in hands” they provide in severely understaffed situations,
Global Health (STEGHs) and Medical Service Trips and the medical services and supplies they typically
(MSTs), have been variously defined as programs that bring with them, their hard work, motivation, adaptabil-
last less than 8 weeks [41] or less than 6 months [24, ity, dedication, high capacity to innovate, and their abil-
25], though the great majority last for 2 weeks on aver- ity to teach specialized skills [22, 30]. Other research has
age [37]. Sponsored by thousands of organizations in the confirmed that host organizations highly value volun-
Global North governmental, corporate, academic, faith- teers with cultural humility and a willingness to learn
based, and secular NGO’s. This growing phenomenon from their hosts, share their technical skills, and provide
brings students and other volunteers to communities in training for local staff, as well as knowledge of the local
the Global South to provide clinical services and sup- language and culture [5, 6].
plies, research and education, and a variety of related These criticisms of STMMs reflect many of the issues
support services intended to improve quality of life. As raised in critiques of humanitarian and development
these programs are almost entirely unregulated, there programs more broadly [13, 23, 35]. For example, as
are no data on their frequency, quality, or cost. Estimates l’Anson and Pfeifer wrote about humanitarian aid, “… in
have suggested that they may involve millions of volun- most cases, NGOs and their supporters are deaf to the
teers and as much as $7.5 billion annually ([38], Paul actual wants, needs, and desires – or, in other words, the
Caldron, personal communication). One study found agency – of those they are trying to aid.” This is a com-
that half of program budgets is spent on airfare [5]. mon concern with STMM’s, which are often driven by
While many of these programs may be beneficial to the needs of volunteers and the assumption that any-
host countries, they have come under increasing scru- thing they offer is better than what communities already
tiny, and serious concerns have been raised by scholars have.
and practitioners across the diverse sectors involved. A Another key concern with STMMs, as with other
growing number of publications have questioned the kinds of humanitarian assistance, is the potential for
value of STMMs and proposed strategies for improving undermining host country professionals. Free clinics and
them (e.g., [3, 24, 25, 39, 42]). free medications offered by outsiders, often assumed to
Critiques center around possible harms to host coun- be superior in their clinical abilities even when they are
tries and patients, including medical errors, non- not, can put local practitioners out of business or com-
alignment with local systems and priorities, cultural in- promise their standing in the community. Similarly, free
sensitivity, and the high cost compared to benefits. A food aid has been seen to create conflict and put farmers
lack of local direction and leadership, questionable ethics out of business [34].
of practice, and whether they appropriately address com- An underlying issue in these examinations of well-
munity needs and provide long-term sustainable benefits intentioned assistance is whether they perpetuate colo-
are all widely questioned by scholars and health practi- nial and neocolonial relationships and feed what has
tioners [24, 25, 28, 38]. Lack of evaluation and oversight been called the “White Savior Industrial Complex” [8].
make it impossible to determine the extent of benefits Fassin and Pandolfi [14] cite the view that humanitarian-
and drawbacks [24, 25, 31]. ism is the “nice face of a new colonialism” (p. 41). Global
Studies of host partner organizations, community health discussions have also recently begun to focus on
members, and staff in a wide variety of countries in the how to “decolonize” relationships between high- and
Global South, which pointed to some key challenges lower-income countries [12].
with managing volunteers and questions about their ef- One element of this “new colonization” is seen in the
fectiveness [2]. For example, there are concerns about imbalance in power and benefits between researchers
volunteers’ lack of cultural understanding, experience from high income countries and those in LMICs who
and preparation, attitudes of superiority, disrespect for often carry out research projects but do not get proper
local customs and practices, and imposing their own credit [27]. Additionally, advocates for Community-
methods and opinions in ways that are inappropriate to Based Participatory Research point out the lack of rele-
the practice environment [20–22, 24, 25]. They also ex- vance and validity in studies of poor communities if they
press a desire for greater continuity of care and better are not designed and directed by those communities [19,
communication with volunteers, both in terms of lan- 44]. Accordingly, the study presented here, unlike almost
guage and in clarity of purpose. Some raise the the entirety of existing literature on STMM’s, does not
Mantey et al. Globalization and Health          (2021) 17:115 Page 3 of 14
come from scholars and practitioners in the Global Table 1 Health facilities in Ghana
North and is not based primarily on anecdotal experi- Type of health facility Number Percentage
ences and surveys of volunteers [7]. While in recent CHPS 4185 61.44
years there has been increased attention to the view- Health Centres 855 12.55
points of host country staff [24, 25, 29, 37], these studies
Clinic 1003 14.72
have been carried out almost entirely by outsiders, many
of whom are affiliated with the programs they write Midwife/Maternity 328 4.82
about. Polyclinic 34 0.50
While the results of these studies are often insightful Psychiatric Hospital 3 0.04
and do capture problems identified by host country staff, District Hospital 137 2.01
the inherent biases posed by social desirability and Hospitals 267 3.92
power differentials when researchers are from the Global
6812 100
North can pose threats to the validity of the results.
The purpose of this paper was to examine the benefits Source: Estimates calculated from Ghana Health Service [17]
and harms of STMM’s from the perspective of Gha-
naians, with the research designed and carried out by In Ghana, demand for healthcare is increasing as the
Ghanaian social scientists. It is likely one of the first population grows. The evidence shows annual out-
such projects and thus of particular interest to health of- patient attendance of 29,741,608 and in-patient admis-
ficials and scholars worldwide. The paper presents the sion of 1,532,845, representing about 53.9 admissions
results of interviews of host staff and health officials re- per 1000 populations in 2016 [17]. Malaria remains the
garding their perspectives on the advantages and prob- topmost out-patient morbidity at 31%, and Upper Re-
lems of short-term medical missions in Ghana. It also spiratory Tract Infections at 17%. Despite the significant
included analysis of the regulatory framework for strides made in reducing infant mortality in 2019 under-
STMMs in Ghana. This paper was part of a research five mortality rates ranged from 31 to 66 deaths per
project, sponsored by Lehigh University in Bethlehem 1000 live births compared to 51.7 for sub-Saharan Africa
PA, USA, which explored Host Country Views on Short- as a whole, there remain critical concerns in this area
Term Health Volunteer Programs. Researchers in three [43]. There are also increasing concerns over maternal
countries that commonly host short-term programs de- mortality being high, although some gains have been
signed and carried out the study; the first country exam- made [40].
ined was Ghana. From this overview, it is established that the health
context of Ghana presents opportunities for medical
Health care in Ghana missions, particularly in the rural and deprived regions
As of 2016, there were 6812 health facilities in Ghana, where there are clear gaps in personnel and health infra-
dominated by Community-Based Health Planning and structure. However, even though STMMs may deliver
Services (CHPS) (61.44%). CHPS is an entry-level health- significant care to underserved populations, the growing
care system designed in 2000 to serve mostly rural com- critique by scholars and practitioners in the Global
munities and to respond to maternal health issues [45]. North raises important questions about how host com-
Health facilities with full hospital status (hospitals and munities and staff perceive these programs [21], the pur-
district hospitals) account for about 6% of the health fa- pose of the present study. Therefore, the core research
cility distribution, as shown in Table 1. The Table is ar- questions this paper seeks to answer are: What are views
ranged based on the distribution of the facilities within of Ghanaians of the benefits of STMM in Ghana (pros)?
the health system. What challenges are associated with STMM in the coun-
In terms of doctors, according to estimates from the try? And what is the Ghanaian regulatory framework
Ghana Health Service [17], there were 3365 doctors, governing STMM, and how widely is it enforced?
with a doctor to population ratio of 1:8000 compared to
the World Health Organisation’s recommendation of 1: Methods
1000 [46]. The evidence shows uneven doctor distribu- Research design
tion across the country; the Upper East Region and the The study used a qualitative design, which combines the
Western Region have the worst doctor to patient ratio of case study approach and political economy analysis. The
1:25,878 and 1: 20,659, respectively. Similarly, the data qualitative research approach was utilised because the
shows that there are about 52,605 nurses in the country, phenomena under investigation could be better ex-
with a nurse to population ratio of 1:542. The Western plained through an in-depth understanding of the expe-
and Eastern regions have the worst nurse to patient ra- riences and perspectives of the target respondents. The
tion of 1:728 and 1:704, respectively. study relates to individual subjective realities and
Mantey et al. Globalization and Health          (2021) 17:115 Page 4 of 14
experiences of STMM with attention to the knowledge were organised accordingly. Where it was not possible
of the regulatory context of STMM in Ghana. The case to hand-deliver the letter, phone calls were made to the
study approach was relevant for exploring the contextual institutions. The project was approved by the Ghana
and experiential issues of short-term medical missions; it Health Service Ethics Review Board and in line with the
involves an in-depth investigation into a bounded unit ethical requirements, all participants were asked to sign
within its real-life context to understand a larger class of a written consent or provide a verbal consent prior to
similar units [15, 16, 47]. In the case of this current re- the interviews. The project was a low risk and did not
search, we considered the Ghana health system relative pose any identified harm to the participants other than a
to medical missions as a bounded system and selected potential discomfort answering questions.
health sector institutions and respondents as elements In all, a total of 24 participants, comprising male and
within the case. The case study relied on in-depth inter- female. Eight (8) Medical Officers, seven (7) Nurses,
views and was useful in examining Ghanaian stake- seven (7) Administrators and two (2) Regulators, were
holders’ views of medical missions. involved in the study and were interviewed in person.
Given that medical missions are complex and involve The in-depth interviews focused on exploring respon-
different actors and different settings, a political econ- dents’ first-hand experiences of medical missions, par-
omy analytical approach was also useful for unearthing ticularly the nature of STMMs. They were asked about
potential institutional, policy and regulatory issues that the countries where volunteers come from, types of ac-
can enhance or inhibit medical missions’ activities cur- tivities undertaken by STMMs, the presenting challenges
rently and in the future [1, 11]. The analysis process associated with STMMs activities and the critical bene-
involved looking into the interview data to extract all fits or outcomes of STMM. The interviews were con-
institutions cited by respondents and examine their ducted by the lead author and two trained Research
roles relating to STMMs. We complemented the data Assistants. The interviews lasted for about 45 min on
with a review of secondary information from policy, average and were conducted in English.
programme and legislative documents available or as cited
by respondents.
Data management and analysis
Data collection An independent professional was recruited to transcribe
The primary data collection for the case study involved the audio recorded interviews. The transcripts were
in-depth interviews with respondents who were purpose- spot-checked by the researchers to ensure consistency
fully selected from healthcare institutions in six regions with the audio versions. The data were largely organised
across the country: Greater Accra, Central, and Western with the support of Nvivo 12 for Windows. Both deduct-
along the coast, Ashanti and Brong-Ahafo in the middle ive and inductive approaches to qualitative coding were
of the country, and Northern region. The selection of used to facilitate the initial coding of the data. Regarding
the regions was based on consulting with known Ghan- the deductive approach, some pre-determined themes
aian experts in public health regarding areas with a high were developed based on the theoretical context and the
concentration of STMM activities. This selection of re- objectives of the current study. Concerning the inductive
gions provided a great diversity in population size and approach, some of the themes and their relevant codes
health care availability and were where many of the emerged out of the data and were not initially developed.
STMMS go. Fig. 1 shows the map of Ghana and the Some of the emerging codes were captured as direct
selected areas where the research was conducted. concepts from the respondents’ words, and others were
The participants worked in a variety of institutions, in- relabelled (given new concepts that retained the original
cluding public and private/faith-based health service de- meaning in order to capture similar meanings from
livery outlets and government entities (regulatory other respondents). The codes were clustered to consti-
bodies). The institutions were selected based on their ex- tute categories (codes that collectively speak about simi-
perience relating to STMMs. Respondents were purpos- lar issues) and labeled according to their respective
ively selected based on their personal involvement in themes, following the research objectives or as a new
volunteer activities in the selected institutions. emergent theme. In some instances, code frequencies
Prior to the interviews, an invitation letter was sent to were derived based on the number of times participants
each identified institution from the categories mentioned spoke about an issue. The codes were initially developed
above. The letter provided information about the re- by one researcher and were validated by the other re-
search and requested an interview with one or two rep- searcher. Both researchers later met to harmonise the
resentatives who could provide answers to the core codes. The interviews were de-identified during tran-
issues of the research. The selected institutions nomi- scription and given unique identifications to ensure priv-
nated their appropriate staff, and the interview sessions acy and confidentiality.
Mantey et al. Globalization and Health          (2021) 17:115 Page 5 of 14
Study regions
Fig. 1 Map of Ghana showing the regions where research was conducted
Results for STMM activities. It is important to observe that at
Sending countries for STMM least two respondents mentioned Ghana as a source of
To set the context for the discussion of STMM, we in- volunteers whom they have worked with. This provides
vestigated the countries of origins of volunteers into some insight into internal STMMs activity in Ghana,
Ghana. This analysis is based on how much information where professionals travel to different parts of the coun-
respondents could recall at the time of the field work try, particularly deprived areas such as the northern re-
and their experiences with STMM volunteers. Overall, gion to provide short-term medical care to deprived
most volunteers to Ghana came from the United States communities.
of America, and this was cited by 14 out of 24 respon-
dents. Britain and Germany followed, with 6 (each) re- Nature of activities of STMMs
spondents citing them as sending countries. Canada (4 In addition to our understanding of respondent’s perspec-
respondents) and other European countries including tive of where STMM volunteers came from, we examined
Czech Republic, Netherlands, Denmark, Finland, the kind of activities or programs they implement. STMM
Switzerland (11 respondents) were also noted as import- volunteers coming to Ghana have diverse skills, and they
ant sending countries. China, Japan, Russia, and Haiti (1 include highly skilled medical professionals, medical stu-
respondent mention each) also sent volunteers to Ghana dents, and other support volunteers. Their programs were
Mantey et al. Globalization and Health          (2021) 17:115 Page 6 of 14
largely undertaken in rural communities and they ad- Table 2 STMM Activities in Ghana, organized by frequency of
dressed the medical conditions prevalent there. Table 2 is mention by respondents
a summary of the core activities of STMM in Ghana. The STMM Activities/Program Code freq %
codes reflect the intensity of the activities being described Community Outreach 48 28
by participants and they have been arranged according to Medical equipment and supplies 39 23
their frequency of mention. While some of the identified
Surgeries and clinical activities 21 12
activities potentially overlapped, each has been made dis-
tinct from the other for the purposes of this analysis. Capacity building for local staff 19 11
Community outreach was the most cited program General consultations 16 9
undertaken by STMM volunteers. This activity involves Student field experience 12 7
volunteers travelling to rural communities of Ghana to Ward activities 7 4
undertake short-term medical activities such as surgeries Knowledge sharing 4 2
and general practice consultations. We used the concept”
Research 2 1
community outreach”, as a distinct descriptor charac-
terised by activity involving travelling outside urban set- Tourism 2 1
tings into rural communities upon arrival in Ghana. To 170 100
reflect this understanding from the data, a respondent
described activities of volunteers in these words: In this instance, volunteers provided training activities
either through workshops or on the job training and
When volunteers come here, we go out to places skills transfer aimed at retooling their local counterparts
where people do not have access to health facilities especially for some of the emerging surgical practices.
but only CHPS1 Compound, and where they do not This activity is reflected in a statement by a respondent,
have access to tertiary facilities like the District and medical officer.
Regional Hospital. So, we go to those areas and stay
there for about a week and we do consultations, pro- At times they come on with skills which is quite dif-
vide drugs and other services, even dental services to ferent from us. As some of our colleagues observe
them. So, we do not stay in health facilities but ra- them and then they would be picking their style of
ther more of an outreach work in the rural areas work and then they can also incorporate it into their
(R3- medical officer). system. (R22 – a medical officer from a regional
hospital).
From the narrative above, it is obvious how volunteers, in
collaboration with their Ghanaian counterparts, undertake Furthermore, some volunteers, according to the analysis,
outreach services in remote communities of Ghana. This undertake general consultations in designated urban
highlights the demand-driven nature of STMM activities hospitals. The process involved having one on one inter-
in a context where there are disparities in access to health- action with patients for the purposes of making diagno-
care between rural and urban communities. ses and providing treatment. Of course, similar
The second most significant STMM activity is the consultations were done as part of outreach programs
provision of medical equipment and supplies Respon- where volunteers have to travel from the city to rural
dents noted that volunteers often bring into the country communities. Other volunteers, such as students and
medical equipment, from sophisticated machines to sim- trainees, used the opportunity as field practice or intern-
ple supplies such as gloves. Some of the narratives also ship Student volunteers who undertook medical mis-
show that volunteers bring medications. This is a signifi- sions in Ghana were sometimes trained by Ghanaian
cant contribution of STMM and fills an important gap counterparts. There were other activities such as ward
in healthcare service delivery, according to respondents. activities where volunteers helped ward nurses to take
Following the supply of medical equipment is the trad- care of patients, administering medication and clean ups.
itional role of volunteers in providing surgical services These ward activities were mostly performed by less ex-
and other clinical activities. The data shows that areas of perienced volunteers or those under training. In
surgical activities include ENT2 services, eye, hernia, fi- addition, we found research as one of the activities men-
broid, cleft palate, and other complex surgical proce- tioned by some respondents. This is how one expressed
dures. Furthermore, respondents cited capacity building the notion of research as an activity of STMM.
for local staff as an important STMM activity in Ghana.
From my experience, I think some come here because
1Community-Based Health Planning and Services of the research aspect of it. They are able to get data
2Ear Nose and Throat and they are able to see the conditions physically
Mantey et al. Globalization and Health          (2021) 17:115 Page 7 of 14
and then be able to get the data to be used for they really do not do a lot of physical examination
research purposes. (R17 - nurse from an urban on the patient, and then they just see the case. They
hospital). are not able to speak to the patient about the fears
and problems that might come up with the operation.
Tourism or sight-seeing also emerged as one of the ac- They are just interested in cutting so they do not talk
tivities undertaken by STMM volunteers. In some cases, mostly to the patient (R17 – a theatre nurse).
tourism was planned and integrated into the work of
volunteers, and in other cases, it was a way to unwind From the above narrative, some patients appear to be
after working hard for two or more weeks. The idea of disadvantaged when it comes to volunteers. Although
tourism was confirmed by a respondent who said: the data show the use of interpreters in certain cases,
the interpreters are usually not professionals, which
The last time they [STMM volunteers] came, we took might increase the likelihood of misunderstanding.
them to Kakum National Park after the surgeries. The second most cited challenge of medical missions
They said they wanted to go to Mole National Park by respondents is the tendency of volunteers to under-
and other places but the days they spent in my facil- mine local knowledge and expertise. This was cited in
ities were sometimes 14 days … and the rest of the 12 cases. Some respondents related occasions where vol-
days are for sightseeing before they go back to their unteers have ignored the expertise of their local counter-
home countries (R1- a hospital administrator). parts, considering them as inferior and to an extent
refusing to comply with local protocols.
Challenges of STMM activities in Ghana
We examined the challenges associated with STMMs This hospital has collaborations where people had
from the perspectives of respondents. Overall, we found come and want to behave as if they are the ones who
9 challenges (74 codes in total) cited by respondents as know and everybody does not know anything. So
shown in Table 3. The most frequently cited challenge those collaborations had stopped over time (Doctor).
of working with volunteers on medical missions is the
issue of language barrier (21%), particularly since most The narratives suggest that patients who were seen by
STMMs activities are concentrated in rural communi- volunteer practitioners also believed that the volunteer
ties, where community members hardly speak any health professionals were superior and better qualified
English. Therefore, from the narratives, there is a limit than their Ghanaian counterparts. This was demon-
to how well volunteers can make connections with pa- strated in circumstances where patients insisted on see-
tients, and this affected the diagnosis process as ing the volunteers who had treated them, even after they
explained by respondents. The point was typified by a had left the country.
respondent who said that: In contrast, one hospital administrator responded to a
question about whether the volunteers are respectful by
Some of the difficulties are that most of them [volun- saying,
teers], because they do not understand the language,
How can they show disrespect? I have my facility
and you walk into it to show me disrespect then I
Table 3 Challenges of STMM organized by frequency of
mentions by respondents would show you the exit [Laughing…] you under-
stand {I: Yes} so when they come they respect us be-
Challenges of STMM in Ghana Code %
Freq cause they are coming to beg for us to accept them to
Language as a challenge for volunteers 16 21.6 come and work in our facility. There is no way they
can disrespect us. That is out of the picture
Undermining local knowledge and expertise 12 16.2
completely.
Pressure on host to provide support services 10 13.5
Fraudulent qualifications, poor skills and lack of 9 12.2 Another commonly cited challenge of STMMs, as shown
Experience in Table 3, is pressure on hosts to provide support ser-
Making wrong diagnosis 8 10.8 vices for volunteers (#10). Host institutions noted that
Unusable medical equipment and supplies 8 10.8 often there were unanticipated costs to them for hosting
Personality conflict 6 8.1 volunteers, ranging from hotel accommodation to trans-
Professional inferiority complex 3 4.1 port and entertainment. The evidence shows that host
institutions do extra work to organise STMM activities
Frustration due to poor equipment 2 2.7
successfully. One respondent confirmed this in the
74 100 following words:
Mantey et al. Globalization and Health          (2021) 17:115 Page 8 of 14
They [volunteers] always mean more work and more guys removed my fibroid but it seems it has come
cost. I told you that we host them in a hotel, you back again.” You check the scan and you see that it
must be prepared to feed them as well and this is true there are more fibroid there but if you the
comes with a cost, but we see it as part of our Cor- Ghanaian doctors do it… because it is a Ghanaian
porate Social Responsibility. Sometimes hosting vol- and an African problem [presuming that the fibroid
unteers means more work, and costs may include the would not have returned if a local Doctor does the
cost of preparing for them, hosting and organising operation] (R1- hospital administrator).
programmes (R1 – hospital administrator- Ghana).
Another respondent notes:
The statement above is indicative of some of the
contributions Ghanaian health professionals and insti- “…different countries have slightly different ways of
tutions make towards STMMs, mainly in the areas of treatment. So sometimes we have misunderstandings.
accommodation, food, transportation, and entertain- But we in Ghana know a lot about typhoid fever;
ment. They also noted the training and oversight of they do not know about typhoid fever so whenever
volunteers. they come here, it is one disease, we have problem
Fraudulent qualifications, poor skills and lack of med- with them. In other words, we think that they do not
ical experience form another set of challenges of STMM know that area and therefore they should probably
in Ghana, representing 12.2% of the code distribution. not be operating on such illness. They should leave
The evidence shows that in some instances, volunteers such cases for us. Diseases that are not common in
present themselves as experts when in fact, they do not their country should be handled by us. So sometimes
have the requisite qualifications to practice. This was we have difficulties getting along with them in that
referenced in the statement below: area (R16 – medical officer).
Sometimes some volunteers came in parading as spe- Furthermore, other challenges cited in the data include
cialists and they turned out to be students and they unusable medical equipment and supplies (10.8%), per-
were now learning. Once you find out that, you need sonality conflict between volunteers and local counter-
to be able to stop them. I know the Medical and parts (8.1%), inferiority complex on the part of
Dental Council is being blamed for being hostile to volunteers when they cannot perform specific local
people outside, but they do this because they need to treatment (4.1%), and expressions of frustration on the
protect the public and guide the profession. So now part of volunteers due to poor or lack of equipment for
they are quite serious and strict about who comes diagnostic purposes. On the non-usability of medical
into volunteer (R6- medical officer from a municipal equipment, a respondent indicated that:
hospital).
Some of the equipment goes through clearing only to
Furthermore, it emerged from the analysis that, given realise that they would not suit your purpose. All
the context of disease conditions in Ghana and the lack these in the name of “donation” or “help” to the
of diagnostic machines that are more widely available in hospital. Meanwhile you have to clear and trans-
high income countries, some volunteers make wrong port them to your warehouse at a cost. You know
diagnoses. This is based on the fact that some of them equipment could come in with manuals that no
do not understand the nature of some diseases such as one could translate. These are some of the chal-
fibroids and tropical diseases like malaria and typhoid in lenges that we have encountered. Some of these
Ghana. This concern was seen in 10% of the total codes things are duly reported to the ministry (R4 –
on the challenges of STMMs. In two cases, respondents hospital administrator).
reported that some patients seen by some volunteers
soon return to the facility due to recurrence. For Another administrator recalled a similar circumstance:
example, a respondent said: I remember (the organization) sent us a 40-footer con-
tainer full of medical equipment…but they did not ask us
I must be frank with you because I told you that before they brought that equipment. They came to ob-
sometimes they [volunteers) manage cases and the serve and then we were there, and they called us that
patient comes back… so the patient will go for 2-3 can we go to the port because a container is arriving.
years and come back that the fibroid has come back. They send us the waybills and items in the container to
Are you getting the point? Those are the challenges go and clear it.
that we have. You have people coming back to com- On frustration on the part of volunteers, a respondent
plain that “oh I came here last year and the white noted:
Mantey et al. Globalization and Health          (2021) 17:115 Page 9 of 14
Sometimes they get frustrated because they do not them. They come to train us on how to use that
have the equipment and access to laboratory facil- equipment. Then they end up leaving that equipment
ities because sometimes, they want to do certain for us.
tests. But for us we have been trained to take a very
good history and examine the patient even without Of critical note is the happiness of patients about volun-
doing laboratory test and with that information we teers, which is often due to the provision of free medical
can give treatment but they cannot. So sometimes care. It is noted that most services provided by STMM
they get frustrated and cannot even work (R3 – med- were free. Since the pressure of payment for medical
ical officer). treatment is reduced when volunteers come, the health
conditions of patients improve faster, according to the
Benefits of STMM activities in Ghana narratives. Thus, patients believe that since they cannot
Despite the challenges associated with STMM activities afford healthcare that they need, their health condition
in Ghana, STMMs have made some important contribu- deteriorates, but it improves when volunteers bring free
tions to health care delivery in Ghana, especially among services and equipment.
poor and rural dwellers. Some of the key benefits of The second most frequently mentioned outcome of
STMM are presented and discussed below. STMM is the promotion of access to healthcare for de-
As shown in Fig. 2, five main benefits emerged from prived and rural communities in Ghana. This was cited
the data. The most frequently cited positive outcome of on 14 occasions by 10 participants who were mostly
STMMs relates to improvement in the health of pa- from rural areas. As noted from the literature, one of the
tients. This was cited by 14 out of 24 respondents on 23 healthcare challenges facing Ghana is the issue of access
occasions and demonstrates that patients who had been to quality healthcare and the unequal distribution of
seen by volunteers had experienced significant improve- health professionals and infrastructure [17]. STMMs,
ments in their health. therefore, help fill this gap and create opportunities for
Improvements in the health outcomes for patients were quality and often free healthcare to benefit poor and
driven by several related factors, some of which include rural dwelling people. For instance, community outreach
the use of modern equipment and supplies by volunteers was highlighted as the most significant activity of
who come along with their own equipment, and a percep- STMMs. A respondent indicated that:
tion of an empathic approach to treatment by volunteers.
For instance, some cite the ability of some volunteers to I think they really do a lot for us because when you
manage very complex medical conditions such as surger- go to the villages that is where you realise that our
ies which contributed to improving the health of patients. health system is very bad. Those in the rural areas
A nurse cited several of these benefits as follows: do not really have access to what a normal citizen
should have. So, most of them stay there with so
Most at times they come with certain equipment we many diseases they are not even aware of. I think it
do not have them and do not even know how to use really helps because sometimes we go there and find
Supply of modern 
equipment 
More empathic care
Patients’ perception of 
better quality with 
Improved health of volunteers
patients (#14)
Enhanced public Patients’ happiness Free healthcare
image of health 
facility (#7)
Ability of volunteers 
Outcomes of Promote access to to manage more 
STMM in healthcare in deprived complex conditions
Ghana communities (#10)
Relief for local 
partners (#4)
Recurring medical 
conditions (#2)
Fig. 2 Benefits of STMMs showing the number of times references were made (code frequency).
Mantey et al. Globalization and Health          (2021) 17:115 Page 10 of 14
out cases especially with the children so we help to well. Some of these includes mandatory registration and
refer them to hospitals, tertiary centres and all that licensing to practice in the country.
for surgeries. So, if we do not go how would these The Ghana Health Service’s Codes of Conduct makes
people know that they have a problem? (R3 - med- it mandatory for all health professionals working with
ical officer) them to be registered and to remain registered with their
Professional Regulatory Bodies. The Health Professions
The analysis further found that STMM activities con- Regulatory Bodies Act, which was developed in 2013,
tribute to enhancing the public image of health facilities also set up health regulatory councils, including the
(cited by 4 respondents on 7 occasions). Respondents Ghana Medical and Dental Council, with the mandate
explained that when volunteers come to their facilities, for ensuring standards, training, registration and regula-
this attracts patients and their families, and as they re- tion of medical and dental professionals. The Ghana
ceive treatment, they form positive images of the facility. Nurses and Midwifery Council, the Ghana Pharmacy
An administrator in a hospital indicated: Council, and the Allied Health Professions Council are
other regulatory agencies with a mission to secure, in
And then it also gives the hospital good image - that the public interest, the highest standards of training and
is it enhances our goodwill because if people are practice. In doing so, all of the Councils have the ability
coming for supposedly free services people think that and authority to provide temporary licenses to health
they get the quality they expect at a lower cost professionals who wish to practice in Ghana for 3
(R10 – hospital administrator). months or less.
Of interest is the Medical and Dental Council’s pos-
Finally, as expected, it emerged that STMM serves as a ition statement on regulation of medical practice as
source of additional capacity for local counterparts to noted below:
ease the pressure of healthcare provision temporarily
(cited by 4 respondents). Respondents noted that volun- It is against the law to practice in Ghana without
teers augment their staff numbers and share knowledge being registered with the Medical and Dental Coun-
and skills with them which is a great source of support. cil of Ghana; it is also unlawful to employ and en-
gage the services of a practitioner who is not
Regulatory frameworks for STMM registered with the council.3
I think the problem with these our volunteers is that As one interviewee from a regulatory council noted, it is
they are scattered, not well coordinated from above, up to the host organizations to enforce the rules for the
so everyone is doing his own thing in his own way benefit of their communities:
but if it was such that there was a coordinated unit,
maybe in the Ministry of Health (MoH) or the Ghana NGOs on the ground are the people who realise that
Health Service… (R5 - medical officer/surgeon). this is a community, and these are the needs, so I can
invite these people to meet those needs (R18 – Some-
The analysis of the regulatory frameworks for STMM fo- one from a professional and regulatory council).
cused on institutional and legislative arrangements for
STMM activities in Ghana. The analysis is based on a Many different governmental and organizational actors
review of government documents and some of the in- are potentially involved in STMMs or could be part of
sights provided by respondents. We asked all partici- the regulation of such activities. Some provide regulatory
pants about their knowledge of laws or policies that and oversight roles through registration and licensing of
regulate the activities of STMMs. Apart from the two re- health professionals. Others provide the policy context
spondents from regulatory institutions, there was no in- and health infrastructure for STMM activities, including
dication from participants that they had any knowledge hospitals and clinics. Even the Ministry of Foreign Af-
of a specific legal or policy framework for STMMs. The fairs contributes indirectly by facilitating visas.
context of regulations for STMM activities is summed
up in the above quotation from a respondent – “every- Discussion
one is doing their own thing”, which is indicative of a The study examined Short-Term Medical Missions
lack of coordination and enforcement of regulation. (STMMS) in Ghana, particularly their activities, benefits,
However, it is our understanding from respondents and problems. Ghanaian participants from around the
from the regulatory institutions that since STMMs oper-
ate within the broader healthcare context of Ghana, the
legal and policy context of healthcare affects them as 3http://mdcghana.org/registration/
Mantey et al. Globalization and Health          (2021) 17:115 Page 11 of 14
country indicate that STMMs there, as in other coun- well as the colonialized attitudes of patients, has been
tries, most frequently conduct outreach to rural commu- cited elsewhere [29] but is more prominently mentioned
nities and provide equipment and supplies [24, 25]. Less here. We found less evidence of direct competition with
frequently mentioned in this study, despite being noted local practitioners than cited in some writings, due to
in the literature as most desired by host country staff the lack of private practitioners in the rural areas.
[37], are information sharing and building capacity of Yet Ghanaian participants often emphasized the value
local staff as key activities. These findings support the of their own experience and ability to provide care with
critique of STMMs that they often do not have any last- limited means and for conditions they know better, in
ing impact. contrast to foreign volunteers. Notable are instances re-
Additionally, studies have found many gifts of equip- ported of convincing the visitors of their capabilities.
ment and medications to be inappropriate and even bur- Thus while the issue of lack of respect that is often cited
densome [9]. This was confirmed by a number of in other studies [26] is apparent here as well, there were
participants who had to go to considerable trouble and a number of expressions of pride at changing those atti-
expense to get equipment they had not requested out of tudes, a valuable finding not noted elsewhere.
customs. For example, a surgeon responded to the question
Community outreach is crucial for addressing the about respect as follows:
rural-urban health need gap since rural areas have lim-
ited healthcare personnel. Yet it is unknown how much Do they feel that they know too much or they are
of this gap is filled by STMMs, which arrive infrequently coming with exceptional skills? May be when they
and are not evenly distributed in rural areas. Where they are coming they will feel so but after sharing know-
do exist, participants cited five major benefits-- im- ledge then they realize that we know what we are
proved health service delivery and positive outcomes for about.
patients who received support through STMMs, en-
hanced public image of health facilities leading to rev- Perhaps the most striking example comes from a hos-
enue generation, relief or additional capacity for local pital administrator:
partners, and the provision of medical equipment and
supplies to facilitate health service delivery. They tell them they are going to Africa and everyone
Despite positive benefits, participants cited difficulties want to go to Africa so they join them to see the
that compromise the effective utilisation of STMMs. black monkeys here [Laughing…] In fact, they come
The most frequently mentioned challenge was language here to see that we are no monkeys after all. You
barriers. As explained by Meuter et al. [32], communica- understand. When they come, they marvel at the
tion is central to the diagnostic process. Effective diag- level of expertise of the Ghanaian doctors and
nosis is a combination of interviews and physical nurses. Sometimes our guys teach them some of the
assessments, and if there is a barrier to doctor-patient things that needed to be done.
communication, the likelihood of error is high. There-
fore, some respondents felt that the problem of language While this comment prompts discomfort, it is perhaps
in STMMs was a cause for concern [10]. A similar find- the most obvious example of the advantage of the study
ing about the relevance of language and culture for med- being carried out by Ghanaians. Surely the comment
ical missions was made by Chiu et al. [7] in a study on would not have been expressed in this manner to an
the perceptions and efficiency of short-term medical aid American, and yet it is a very powerful evocation of the
missions carried out by Taiwanese health professionals. many positive as well as troubling dimensions of
And while other studies have noted the problem of STMMs. Interviewers noted that participants often
language gaps [16, 22], none have indicated it to be the switched to the local language to answer questions asked
leading challenge. in English, even though the latter is Ghana’s official lan-
The second most frequently cited challenge is that the guage and all participants were fluent in English. This
volunteers may undermine local professional’s standing. tendency, along with side comments such as “you under-
This is seen in the observation that some patients who stand”, as seen in the quote above, indicate a level of
were seen by volunteer practitioners believed them to be openness and comfort that is necessary for research.
superior to and better qualified than their Ghanaian Another important contribution of this study is our
counterparts. This finding is similar to an observation analysis of Ghanaian regulations governing medical
made by Nouvet, Chan, and Schwartz [33] in their study practice, as well as our questioning of study participants
of medical missions in Nicaragua. The lack of respect about their awareness of these regulations. The fact that
for the expertise of host country practitioners, arising there are requirements for approval for anyone seeking
from the ignorance and biases of visiting volunteers as to practice in Ghana, and yet none of the staff
Mantey et al. Globalization and Health          (2021) 17:115 Page 12 of 14
interviewed were aware of them, reveals an important fac- their volunteer visitors are properly registered. However,
tor contributing to the problems with STMMs not ad- most local practitioners did not indicate an awareness of
dressed in other studies. such provisions. And we are unable within the current
Based on the narratives of some respondents, juxta- data to ascertain what proportion of medical and dental
posed with the respective legislative and regulatory ar- volunteers actually do register with the Council. As
rangement, we conceptualise what the institutional alluded to by a respondent – “everyone is doing their
regulatory structure for STMMs could be in Fig. 3. The own thing”, there are indications of some, or perhaps
figure shows the Ministry of Health as the apex regula- most, volunteers avoiding the public regulatory system.
tory institution providing both legislative and policy con- The regulators confirmed that they sometimes register
text for STMM. Beneath Ministry is the Ghana Health and license volunteers when an application is made to
Service (GHS) with a mandate to coordinate, deploy them. However, they had well-founded concerns about
staff, and implement healthcare programs. The GHS has volunteers possibly escaping the regulatory system.
an oversight role over the three regulatory institutions of
healthcare including the Pharmacy Council, the Nurses Conclusions
and Midwifery Council, and the Medical and Dental The challenges posed by international volunteers are
Council. These regulatory institutions have the mandate often overlooked by host country officials because the
to register and license healthcare professionals including activities largely take place outside the regular healthcare
Volunteers. Below the authority structure are the health- delivery system. Sponsoring organizations in the Global
care facilities, health-based not-for profit and faith-based North are also not subject to regulations, and visiting
organisation with interest in health care. These institu- volunteers assume that oversight is not needed because
tions mostly have direct relationships with STMM. As whatever they offer must be better than the “nothing”
shown in the conceptual regulatory structure, there is a they assume they will find [24]. Competing priorities
weak link between the major regulators and STMM ac- leave regulation of STMMs ignored [25].
tivities and this raises concerns for the enforcement of The results of this study lead to the recommendation
regulations. that challenges of STMMs should be given attention in
It is mandatory for STMM volunteers to register with order to reduce the ineffective utilisation of the pro-
the regulatory Councils prior to their temporary prac- grams. For instance, healthcare professionals from send-
tice. It is also mandatory for local partners to ensure that ing countries should have the requisite skills, knowledge
Fig. 3 Conceptualization of institutional regulatory structure of STMM
Mantey et al. Globalization and Health          (2021) 17:115 Page 13 of 14
and experience to meet the needs of the identified coun- legislative analysis. Efua Mantey and Daniel Doh performed the data
try and community, as determined by those communi- analyses. All authors contributed to writing of article. The author(s) read and
approved the final manuscript.
ties. Regulatory agencies in Ghana are charged with
evaluating qualifications and should do so for short-term Funding
volunteers. This will require better communication of This study was fully funded by Accelerator Grant (Lehigh University).
the rules to host organizations as well as to sending
Availability of data and materials
organizations. Data would be available upon request.
Sending countries or mission organisers should involve
host countries in the planning process to clearly identify Declarations
the health needs of the host communities. Also, the in- Ethics approval and consent to participate
stitution and councils responsible for health services Ghana Health Service Research Ethic Board (GHS-ERC005/03/18) grant
should be able to coordinate and oversee the activities of approval for the study. Also approved by Lehigh University Institutional
Review Board (1223538–1).
STMMs to avoid unethical practices that could lead to
abuse and to ensure equitable distribution of their activ- Consent for publication
ities to areas of need [36]. Not Applicable.
Despite the availability of these regulatory institutions,
Competing interests
their level of control and coordination of volunteers who I wish to confirm that, there are no known conflicts of interest associated
practice in the country is unclear. Therefore, as an ex- with this publication and there has been no significant financial support for
ample, the basic data on the number of volunteers per this work that could have influence its outcome.
year and their respective originating countries are not Author details
available due to the lack of coordination. Most striking 1Department of Social Work, University of Ghana, Legon, Ghana. 2Centre for
is the finding that none of the Ghanaian health profes- Social Policy Studies, University of Ghana (Now at Western Sydney), Sydney,
NSW, Australia. 3Lehigh University, Bethlehem, PA, USA. 4Department of
sionals interviewed were aware of the regulations. Surgery, School of Medical Sciences, Department of Maxillofacial Sciences,
There is a need for all stakeholders in the health sector Dental School, College of Health Sciences, Kwame Nkrumah University of
to have a dialogue about the future of STMMs so that Science and Technology (KNUST), and Komfo Anokye Teaching Hospital,
Kumasi, Ghana. 5Medical and Surgical Skills Institute, Korle-Bu Teaching
Ghana can position itself to maximise the benefits and Hospital, Korle-Bu, Ghana.
reduce the risks. A number of the personnel interviewed
evidenced confidence in their own abilities relative to Received: 17 March 2021 Accepted: 20 July 2021
outsiders and the experience of rebalancing relationships
in a more equitable way. Finally, this study supports the References
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