Brocher Declaration

We, the undersigned, call on the international community to acknowledge the impacts of short-term engagements in global health. We urge medical professionals, educators, religious organizations, nonprofit organizations, and other entities that participate in these short-term engagements to do so with the awareness of the challenges and concerns outlined by this coalition, as well as with the responsibility of upholding social and ethical standards.

We recognize that:

Global health as a field of practice should aim to reduce disparities in healthcare access and quality.
The ethical framework that underlies global engagement is based on principles of mutual respect, solidarity, and social justice.
Communities’ needs should be the most critical driver of these activities and should be set by members of the communities themselves in conjunction with the health priorities of the country.
Global health engagements should preferably be sustainable, asset based, bidirectional, adhere to appropriate legal standards, and be adequately evaluated.

Short-term engagements have been critiqued for not considering community needs and for sometimes causing more harm than good to individual communities and health care systems. It is crucial for visitors from high income countries to shift the paradigm from viewing host communities as the “other” to viewing them as not dissimilar to the patients at visitors’ home communities, while acknowledging the differences in needs, culture, and health resources. Additionally, short-term global health activities must incorporate the most effective and equitable use of often-limited resources while building the host community’s health workforce capacity so that Universal Health Coverage goals are met.

We hold that these following principles should guide all global health engagements:

1) Mutual partnership with bidirectional input and learning
Health care in different settings varies greatly in terms of cultural and social determinants of health, languages spoken, clinical protocols, and health system realities that depend on political and economic conditions. This often leads to misalignment of short-term global health partnerships and the host country workforce. Global health engagement should emphasize mutual partnership and bidirectionality to facilitate mutual learning.

2) Empowered host country and community define needs and activities
When short-term global health engagements are landed on communities based on a perceived need or an available skill, they undermine the local voice in defining the health care future of the community while diverting much needed funds and efforts away from real needs. This can be exacerbated by power differentials between people in high- and low-income countries. The host country should drive the agenda for healthcare work. This begins with empowered host communities who understand specific needs for health care and indicate the activities that would lead to sustained health improvement. Special emphasis should be placed on the social determinants of health and the relevant Sustainable Development Goals (SDG).

3) Sustainable programs and capacity building
Global health programs should aim at capacity building within local communities such that important health care needs of local communities are met and strengthened. This is possible when programs have sufficient input from the local communities and are committed to long-term healthcare development and sustainability. The overarching goal should be one of strengthening health systems rather than providing unsustainable alternatives.

4) Compliance with applicable laws, ethical standards, and code of conduct
Quite often, short-term engagements do not consider the existing legal framework in the community they engage in. Clinical care has been framed within the context of the classic bioethical principles of autonomy, justice, beneficence, and non-maleficence. Engaging in global health activities requires entities to consider other ethical principles including social justice, social contract, and utilitarian principles. Short-term global health partnerships must establish and abide by common quality principles for all stakeholders.

5) Humility, cultural sensitivity, and respect for all involved
International health volunteers and the organizations that coordinate their work often have motivations other than contributing to the health of people in host communities. These experiences can be seen as privileged volunteers gaining social capital at the expense of disadvantaged host communities. To alleviate this dynamic, those participating in short-term engagements must respect the culture, history, strengths, and weaknesses of the communities they are visiting, while simultaneously recognizing the limitations of their cursory understanding as a non-member of the community.

6) Accountability for actions
The overall emphasis of global health engagements should be on long-term health improvement of host communities. Global health engagements should be evaluated appropriately so that outcomes, unintended consequences, and spillover effects are reduced. If these standards are not upheld by short-term global health engagements, or if they cause more damage, they should be altered or ended.

We call for efforts towards the ethical execution of short-term global health engagements. Such activities are currently unregulated and have the potential to cause more harm than good. We firmly believe that the needs of the host community must be the primary driver of short-term global health engagements; and to achieve health equity, the care provided by these activities must align with national health plans and strategies. In addition, we encourage participants to uphold the same standard of providing valuable care to host community members as they do to their home communities and shift the paradigm of “other” to alleviate the social and ethical issues involved in this work. Furthermore, we ask individual countries to regulate global engagements to ensure that ethical and legal requirements are met. By actively working towards the execution of the principles outlined above, we hope to improve global health work and most importantly, the impacts of that work on host communities.