Do mission hospitals have a role in achieving Millennium Development Goal 5?

3.1. Mission hospitals integrated into the health system 

In some countries mission hospitals currently make up a large percentage of functioning facilities and their role in providing health services is greater than is generally known. For example, in Haiti almost half of all hospitals are operated by FBOs. Mission hospitals provide a third or more of all clinical care in Cameroon, Ghana, Malawi, Zambia, and Uganda. In Bolivia, FBOs own a quarter of health facilities in the 3 largest cities and they supply more than 10% of clinical services in Indonesia and India [5].

Some African governments have already integrated church-run hospitals into the national health system. The Democratic Republic of Congo, Malawi, and Tanzania have all partnered with mission hospitals and delegated responsibility to them for underserved regions [5], [8]. In the Muanza region, 4 of 10 district hospitals are mission hospitals while in the Kigoma region, 2 of 5 district hospitals are mission hospitals. In Lesotho, 9 of the country’s 18 health districts are headed by mission hospitals, which carry out comprehensive health planning and management for their districts. In Zimbabwe, government funds for rural health improvements are used to expand mission facilities designated as district hospitals and to buy ambulances for these hospitals [5].

3.2. Where mission hospitals are independent and not discouraged 

In India there are 238 Christian hospitals and 42 health centers that are distributed throughout all states [9]. Pakistan has 26 mission hospitals and 38 mission-run health centers [10]. Without these services coverage in some areas would be limited, yet local and national governments may ignore them. Mission hospitals may take on leadership roles, especially in training, without formal integration into the national health system. For example:

3.3. Where mission hospitals are discouraged or banned 

After Mozambique’s independence in 1975 the government banned NGOs’ (including FBOs’) heath activities in favor of government-run facilities, suddenly eliminating a wide range of rural health services [5]. Similarly, after the 1979 revolution in Iran most of the mission hospitals were taken over by the government and the quality of services declined.

4.1. Working environment 

Most mission hospitals have a “corporate culture” which values and encourages compassionate services, even at the expense of personal comfort and career enhancement. Research in Uganda found that religious not-for-profit health care facilities—where qualified medical staff earn less than market wage—were more likely to provide services with an element of the public good [13]. Qualitative research on staff attitudes in Malawi found that after joining mission hospitals, attitudes and behaviors toward service markedly improved. [14].

4.2. Financial support through international churches and mission organizations 

Faith-based hospitals and clinics often have long-term relationships with their founding boards, resulting in donations of money and medical supplies far beyond what is locally available. This access to external funding gives a degree of autonomy to hospital administrators and fosters a “can do” attitude toward necessary improvements even when government funding is limited. It often allows for flexibility in patient charges, including sliding scale fees or free care for those who cannot pay. The fees for maternal health services are often higher at public than at FBO facilities. A survey of facilities in Malawi, Ghana, and Uganda found that although in Malawi and Ghana public facilities were more expensive for patients than mission hospitals, in Uganda the reverse was true [15]. In Zimbabwe, a study in 4 hospitals found that costs to the hospitals per inpatient admission were 40%–50% lower at the 2 mission hospitals than at 2 government facilities. Outpatient costs per visit were up to 4 times higher at the government hospitals than at the 2 mission hospitals [16].

4.3. Access to trained, committed expatriate experts who often work as volunteers 

The number of long-term expatriate medical missionaries has declined in recent decades but still makes up a significant proportion of skilled personnel and leadership in mission hospitals and clinics. Short-term volunteer medical professionals often assist with in-service training programs, focused surgical camps, and evaluation of ongoing programs. These volunteers encourage and educate local staff by promoting evidence-based medicine, the initiation of new appropriate technologies, and ongoing support for leadership development.

4.4. Human resources 

Decentralization sets FBO facilities apart from government ones in maintaining a high level of job performance. In mission hospitals the responsibility for hiring and firing of staff falls to on-site administrators, not to more remote district health or ministry offices. Supervision is more effective as daily staff presence and performance can be directly observed, appropriate feedback given for correction, and problems resolved quickly.

4.5. Continuous supply of essential drugs 

In the decentralized system of procurement and supply adopted by many FBO facilities, managers are authorized to order required drugs and supplies directly. In central government essential drug programs, on the other hand, stock-outs, delivery delays, and unequal distribution are more common. In Tanzania, research found that mission dispensaries were more likely than government dispensaries to have chloroquine and penicillin in stock (90% vs 50% for chloroquine and 70% vs 20% for penicillin) [17]. Managers of FBO hospitals may negotiate directly with vendors and procure supplies at competitive rates. In some countries, including Kenya and Nepal, a network of mission hospitals uses a centralized system for selecting and procuring drugs. [18] These centralized systems are managed by professionals who develop an appropriately limited pharmacy based on WHO’s Essential Drug List and the needs of each facility. They also provide guidelines for rational use of drugs, and monitor their quality and expiration. This benefits the quality of EmOC, as shown by the earlier availability and adoption of magnesium sulfate for eclampsia prevention and misoprostol for postpartum hemorrhage prevention in some mission hospitals compared with government hospitals (personal observation of author — MC). In Kenya, a formulary committee comprising clinicians from mission facilities, representatives from the Essential Drugs Program (EDP), and Mission for Essential Drugs and Supplies (MEDS) pharmacists periodically review and update the drug lists based on prevailing disease patterns, changing treatment guidelines, and evidence-based recommendations. MEDS monitors each of the 900 FBO health facilities to assess needs and distributes drugs accordingly. Based on the success of this Kenyan program, Tanzania, Uganda, and Malawi have also started similar EDPs. Levin et al. [15] confirmed a continuous flow of pharmaceutical supplies to mission hospitals which they attributed to good management and efficient use of resources at mission hospitals. Gilson et al. [17] report that clients felt mission facilities provided more satisfactory care than at government facilities mainly because they were more likely to receive the drugs they needed.

4.6. Clinical care 

One of the UN indicators for quality of EmOC is the case fatality rate (CFR) [19]. Table 1 shows that in Tanzania the CFR at mission hospitals in the Muanza and Kigoma regions was lower than at government hospitals [20]. A recent journal editorial described the case of a woman who died in a mission hospital (in an unidentified African country) after transfer from a government hospital where she had spent 2 days without being treated [21].

Table 1. Comparison of case fatality rates and staffing in mission and government hospitals in Muanza and Kigoma regions of Tanzania

		Mission hospitals		Government hospitals
		Mwanza (n=4)	Kigoma (n=2)	Mwanza (n=6)	Kigoma (n=3)
	Medical officers (MO)	6	3	6	7
	Assistant Medical officers (AMO)	12	6	32	19
	Average staff per hospital (MO & AMO)	4.5	4.5	6.3	8.7
	Number of complicated deliveries	1768	368	2764	1885
	Average complicated deliveries per hospital	442	184	461	628
	Average complicated deliveries per staff person	98	41	73	72
	Case fatality rate (%)	0.9	0.5	2.6	1.4

Reprinted with permission from Mbaruku et al. [20].

In Tanzania, the quality of EmOC at mission hospitals is also recognized by the community. As they have gained a reputation for prompt and effective response to emergencies, FBO hospitals receive a higher percentage of obstetric complications than government facilities [7]. Gilson et al. [17] assessed general performances at both FBO and government dispensaries. Mission hospitals scored higher than government ones on the criteria used for obstetric and other medical services, including infection prevention and wound care. This was attributed to the lack of training and the low morale of many government health workers. A comparison of obstetric services in government and mission facilities within the same districts in Malawi, Uganda, and Ghana found that all 6 mission facilities outscored their government counterparts in use of standard protocols for laboratory tests, prenatal care, pelvic and other physical assessments, and use of partograms [15].