Humanitarian Action: A Necessity in the Academic Training of Health Professionals

Abstract

In an increasingly complex world, many low and middle-income countries (LMIC) lack access to proper water and sanitation, have scarce economic resources, and have weak public health systems. With limited funds to cover this gap and day-by-day worsening panorama of day, international agencies need to meet aid projects with ever-increasing quality and efficiency requirements. Aside from the increasing budget, this implies the creation of quality training programs in universities that do not exist specifically. The need for theoretical-practical training on aspects related to global health problems, migratory movements, geopolitical world history, human rights, security, health care for vulnerable populations, and how to create specific health action plans to improve related outcomes, etc., makes unavoidable to improve necessary conscience and skills on this problem from the first steps of health science students’ career to professional postgraduate teaching programs. The objective is to equip health workers with specific tools under a systematic wide approach to issues that, till now, have not been included in undergraduate studies of the health professions and constitute a complex framework of comprehensive knowledge.

1. Introduction

Today, the world—and the most vulnerable communities in particular faces increasing fragility and fragmentation due to the COVID-19 pandemic, extreme weather events, protracted conflicts, and an increase in migrants, both internally displaced, crossing borders every day.

The 76th World Health Assembly, held in Geneva (Switzerland) from May 21 to 30, 2023, constitutes a good example to allow us to summarize several relevant topics that were discussed, covering not only the rich countries but all humankind, even in difficult humanitarian situations. For this reason, the fundamental advances in the UHC (Universal Health Coverage), the pandemic treaty and the modification of the health regulations international law, the emergency fund, or the serious health situation in Palestine or Ukraine due to the occupation and increased hostilities. Other topics covered have been the Health Initiative, Strategy for Peace, or the review of the Global Strategy for the Health of Women, Children, and the Adolescent (2016–2030), which are related to specific vulnerable population groups.

This year, several events with an important specific weight both from the point of view of climate change, United Nations Climate Change Conference 2023, COP28, which will take place from November 30 to December 12, 2023, in Dubai (UAE) as from the point of view of decisions or high-level meetings of the United Nations, including the pandemic preparedness and response plan, UHC and the high-level meeting on tuberculosis.

As the bigger threat to health and global warming, we are living in a history of unprecedented rise in the global temperature of more than 1.2°C since the Industrial Revolution. Various experts from the scientific community and United Nations agencies, such as intergovernmental panel on climate change (IPCC) or UN environment programme (UNEP), try to address this situation and warn about the need for stick to signed agreements to limit uncontrolled emissions. The consequences of this on ecosystems and health are evident. This increase in global temperature is responsible for the rise in sea level, the reduction in agricultural activity and the increase in droughts, among others. These situations have a real impact on health, increasing, for example, the distribution of infectious diseases such as malaria or worsening mental health or mortality due to heat waves.

Climate consequences are worse in low and middle-income countries (LIMC), which has contributed less to the emission of these sources of greenhouse gas emissions (GHGs). These countries, due to the interaction of climate change with other stressors, will be scenarios of conflicts, and millions of their inhabitants will be forced to immigrate to less affected areas, so the current political crisis, conflicts, and riots in many Middle Eastern and African countries have led to massive migration waves toward Europe [1]. In fact, the health crises related to climate change in African countries are predicted to get worse and more prevalent. The response to catastrophic events such as cyclones, flooding, and landslides must be rapid and well-coordinated. Slower adverse events such as droughts, heat stress, and food insecurity must similarly be anticipated, planned for, and resourced. There are lessons to be learned by the health system following the crisis created by Cyclone Idai in Zimbabwe in March 2019, which required a massive humanitarian response to mitigate the impact of torrential rainfall on lives and livelihoods [2].

The WHO Eastern Mediterranean Region, extending from Morocco in the west to Pakistan in the east, with a population exceeding 490 million, suffers a large proportion of both natural and man-made disasters. Humanitarian partners in the health sector have played a major role in averting excessive mortality and morbidity in response to previous emergencies; nevertheless, much remains to be done to provide evidence through rigorous research methods to standardize other essential elements of the health response to humanitarian emergencies. Strengthening academic institutions, prioritizing research, and utilizing financial resources and linkages with institutions in the developed world can ameliorate the situation in the region [3]. These responses may be professional and people from agencies must be properly trained.

The existence of vulnerable countries with poor health conditions, scarce resources, and deficient and/or unstructured health systems requires international agencies to comply with ever-increasing quality requirements. This implies the need to create training programs that do not exist specifically in universities without losing the momentum of applied research and knowledge transfer. Given the number of people affected annually and the likelihood of such events increasing in quantity and intensity, it is important that educational outcomes cover the needs of affected populations.

Reliable and timely information on the health status of and services provided to crisis-affected populations is crucial to establishing public health priorities, mobilizing funds, and monitoring the performance of humanitarian action [4]. Although the development of humanitarian action is rooted in historical events, the dynamics behind today’s international relief organizations can only be understood within the context of the modern world. Relief organizations are currently confronted with major challenges and paradoxes. The challenges include the need to enhance professionalization and standardization of assistance operations and exposure to greater risks [5].

It is necessary to explore the case for professionalizing humanitarian action through an international professional association, the development of core competencies, and the creation of a universal certification system for aid workers. International humanitarian response to crises employs many people and accounts for billions in spending globally each year. Most action is carried out by not-for-profit organizations working with United Nations (UN) agencies, military organizations, and commercial entities. Training and research are needed. UN agencies employ many technical experts, but yet there is no international professional apparatus to promote the quality and integrity of this workforce [6]. The professionalization movement endorses a standard route to certification through the completion of a competency-based curriculum, demonstrating competency through examination or experience to produce learning. These programs devise certification criteria for entry, mid-level, and higher-level candidates who serve in domestic and global humanitarian crises [7]. Training and research are needed. Classical in the air message of “do not harm” message is not enough without a systematic background.

This implies the creation of quality training programs in universities that do not exist specifically. The need for theoretical-practical training on aspects related to global health problems, migratory movements, world history, geopolitics, rights, security, health care for vulnerable populations, and specific health action plans to improve related outcomes makes it necessary to consider providing professional postgraduate students with tools on issues that till now are not explained in undergraduate studies of the health professions.

Students, applicants to medical school often state that they are motivated by a desire to help others, despite the assessment of altruism is difficult and imprecise, in fact altruism is not an observable behavior that can be measured [8, 9]. Studies carried out in German reflect that altruism tends to increase for last year students who assist in clinical practice, is higher for females, and altruistic medical students are more likely to choose surgery and pediatrics as their preferred specialty [10]. Otherwise, the university student volunteer as a social change agent is in a period of transition. There is no returning to the idealism and activism of the 1960s. In view of the changing nature of today’s students, the conventional definitions of volunteers must be reconsidered due to there is widespread disillusionment with “band-aid” approaches to solving enormous social problems, i.e., trying to help the few while some of society’s most fundamental structures guarantee the perpetuation of poverty, crime, and general anomie. Altruism and volunteers are needed, but not only.

For teaching humanism and professionalism, the best is modeling it and the example of the Baylor College of Medicine (BCM), which “adopted” virtually all the medical students of Tulane University School of Medicine and continued their education for 8 months after most of New Orleans was flooded on August 29, 2005, after Hurricane Katrina, in which, after the BCM-Tulane experience, BCM developed a disaster-management plan that could help other schools as they plan for disasters [11].

Some authors have identified training programs, most of them available in few countries of the global North, and few qualified for a master’s degree in humanitarian health using theoretical knowledge as the most common method used for teaching and assessment, but the duration of the training and tuition fees were different for different programs and qualifications, while target audience, prerequisite, and curriculum design were often vaguely described or missing [12].

Humanitarian action is developing in an increasingly changing and troubled world context. Organizations are subject to more and more complex requirements due to ethical, legal, technical, financial, media-related, and political considerations. They must deal with higher and higher stakes, such as the emergency-development trade-off, the need for professionalization, and the revival of governmental humanitarian action.

Non-governmental Organization (NGO) gives to the education of health staff on humanitarian aid interventions and educational activities that contribute to the quality of aid activities in situ and needs to be different totally for each of the association’s standard forms of humanitarian interventions: urgency, post-urgency, development for technical assistance [13]. Examples in humanitarian teaching are, among others, the increased demand for humanitarian logisticians with a humanitarian logistics competency framework (HlCF) designed to support the human resource plans and practices of aid agencies, which will, in turn, facilitate workforce mobility and support the overall concept of a certified humanitarian logistics professional. Others are the competences required in the humanitarian context, whereas current occidental surgical training through courses addressing the specificities of surgery in the humanitarian setting and austere environment is aimed at trained surgeons and senior residents interested in participating in humanitarian missions. Teaching humanitarian surgery by joining academic and field actors seems to fill the gap between high-income country surgical practice and the needs of the humanitarian context [14]. Some other examples are the objectives of the CESHs (the European Center for Humanitarian Health Care) Educational Program that teaches the principles and methods necessary to integrate experienced teams already in the field. Courses including a three-week study program sanctioned by an Interuniversity Degree in Public Health and several 2-to-3-day training modules for humanitarian actors including field workers and decision-makers, health care professionals, and governmental or other administrative agents [15].

Given that the humanities and social sciences are underrepresented in the studies of the Degree in Medicine, it is necessary to cover these aspects at the postgraduate level [16]. As other authors have proposed, there is no agreement on core curriculum or pedagogy across humanitarian studies courses or consensus on what it means to hold a Master’s in this field, so it is necessary to provide students of the health professions with tools of this type, training them in theoretical-practical content on global health problems, migratory movements, history, geopolitics, rights, security, health care in vulnerable populations, specific health plans for performance, etc. [17].

It is important that these courses further contribute to an improved humanitarian sector, and programs must include course entry requirements, flexibility, research, practical components, and academic foci. A second implication concerns pedagogy.

Health interventions have undergone changes, and the new situations that these professionals face make it necessary to pay attention to different issues without losing sight of the need for a good relationship between teaching and research. The Faculty of Medicine and Health Sciences of the University of Alcalá (UAH) shows off its involvement in social responsibility in the face of a changing world, and with this official postgraduate, it becomes the only Faculty of Medicine of a public university that offers a study of this type. So, since the 2017–2018 academic year, offered between the UAH and the humanitarian action organization Doctors of the World, there is an official blended 90 ECTS master’s degree that uses the Blackboard platform. A video on the essence of the study can be seen at the following link https://www.youtube.com/watch?time_continue=1&v=OJCqvXDoA0k.

Ahead, 2260 hours of training—spread over a year and a half—divided into ten modules (8 modules of 8ECTS with modular internships + a module of external internships in the field of 14ECTS+ a TFM module of 16ECTS) in which different entities collaborate. The study plan, teaching guides, evaluation of the contents, schedules, teachers, commissions, academic and quality, quality management, etc., appears in the link of the official page of the postgraduate Service regarding University Masters https://www.uah.es/es/estudios/estudios-oficiales/masteres-universitarios/Accion-Humanitaria-Sanitaria/. From the study we have also developed an external website that can be consulted at the following link https://master-universitario-en-accion-humanitaria-sanitaria-muahs8.webnode.es/.

1.1 The health humanitarian action master degree

The humanitarian sector has grown enormously over the past two decades, and some studies reflect (only those in the English language) an increase over the last 20 years in postgraduate studies in humanitarian action, called Masters of Humanitarian Assistance (MHA) that offers differences in coverage, but there is no agreement on core curriculum or pedagogy across humanitarian studies courses [17].

We offer a Master’s program that supports the development of humanitarian action at the academic level with the intent of creating health workers with a high level of professionalism, ready to be deployed with governmental and non-governmental organizations. The educational structure is based on a multidisciplinary and competency-based approach. Learning takes place through a combination of traditional and innovative educational methods. The didactic approach utilizes a self-directed e-learning curriculum. In the e-learning phase, students are involved in virtual team-working exercises and learn at their own pace under the guidance of tutors. Students meet peers and faculty, attend lectures, participate in debates, and engage in complex simulations. One of the main strengths of our Master’s program is the presence of members with field experience in humanitarian large-scale emergencies. The face-to-face practices that are carried out in each module work on and delve into various aspects of the reality that student will encounter when they carry out their external practices in the field. Students make their field practices in those countries in which Doctors of the World have active health programs. Finally, the Master’s degree is awarded upon the successful completion of an online proctored examination and upon the defense of an original Master’s thesis, with the expectation of publication in a peer-reviewed journal.

Specifically, we consider it necessary to dedicate a space to the description of the contents divided by three semesters:

• First semester: Module I–Module IV

• Second semester: Module V–Module VIII

• Third semester: Module IX–Module X

Module I: The basic principles of the bodies of law that are related to humanitarian action are discussed. In order to understand both the ultimate causes and the consequences of emergencies, the international geopolitical situation in relation to conflicts and human crises is analyzed, and both causes and consequences are discussed. This module studies the different international organizations that act in a humanitarian crisis and how coordination occurs between them.

Module II: The basic minimum requirements are discussed to respect the right to human dignity in health and its determinants through the Sphere Project, the need for participation, and the principle of doing no harm with the Core Humanitarian Standard. Based on this concept, the fundamental contents of Public Health in Humanitarian Action are developed, both in relation to the study of the health context and common, acute, and chronic pathologies, which manifest themselves in an emergency context.

Module III: The fundamental contents of medical assistance in Humanitarian Action are developed, evaluating the existing local health system and intervening in its consolidation. It focuses on the different aspects related to primary, secondary, and tertiary specific processes for the management of nutrition problems, mental health and psychosocial well-being, sexual and reproductive health, emergency care in situations of multiple victims, and surgical interventions.

Module IV: The fundamental contents on epidemics are developed, both at a general level and those specific, in relation to interventions; everything that concerns the development of vaccination campaigns is studied, and the particularities of assistance in emergency situations caused by natural or anthroponotic catastrophes are focused.

Module V: The fundamental contents of the project cycle in emergency phases are developed, as well as the management and the different types of financing of the projects.

Module VI: The basic contents of logistics in a Humanitarian Action intervention are developed, framing them in three blocks: knowledge of the Security Management System and its components, the supply and supplies cycle, the different external communication strategies, and the internal necessary to work on emergency projects.

Module VII: The future perspectives of humanitarian action are discussed in terms of political implications and access to vulnerable populations, as well as the millennium development goals (MDGs) and their transition toward the sustainable development goals (SDGs) and the 2030 Agenda in terms of challenges in the health sector. A review of official development assistance (ODA) in health is carried out.

Module VIII: The fundamental contents are developed in relation to recovery, resilience, empowerment, participation, and post-emergence sustainability.

Module IX: External internships are carried out in the field in the camps for displaced persons, and for this, they have field tutors. In those years students have implemented their training in different countries in which work Doctors of the World.

Module X: It is dedicated to the development and defense of the Master thesis that consists of carrying out research work, writing a scientific report, and presenting it before a court. The Master’s thesis is framed in the work topics of the different teachers participating in the Master’s. The necessary means (space, instrumentation, materials, bibliography, and access to databases) and the advice of its director, doctors belonging to the academic staff of the Master are provided. Students will have an adequate, academic and professional supervision, and with the recognition and protection of the intellectual property of the Final Master’s Project.

The work developed allows in the future to tackle more ambitious projects such as the doctoral thesis or developing professional activities in the academic, research, health, or humanitarian action field. The training activities and evaluation methodologies are appropriate for a Master’s Degree with a humanitarian health profile, which has sufficient and adequate coordination mechanisms, and the admission criteria are adequately applied.

The degree has an Internal and External Quality Assurance System whose structure is effective and useful for promoting quality and allows for the identification of strengths and weaknesses, as well as proposing improvement actions to reduce or eliminate them. The resources of spaces and equipment are adapted to the number of students, the training activities, and the teaching organization. Mobility is guaranteed since the centers (Alcalá University and Doctors of the World) have the necessary infrastructures to eliminate architectural barriers. In addition, the necessary adaptations are carried out to favor the inclusion of enrolled students with disabilities. The Alcalá University Guidance Service offers students the necessary support and advice, both academic and work. Likewise, students have the necessary tools and infrastructures to achieve learning outcomes, both theoretical and practical.

The training activities, the teaching methodologies, and the evaluation systems and instruments are oriented toward the effective achievement of student learning results. The implemented study plan, with its corresponding subjects, adequately covers the competencies of Spain ministerial order CIN 352/2009, and the learning results satisfy the Spanish qualifications framework for higher education (SQFHE) Master’s level.

Another important question is the evaluation of the teaching learned. There are very few examples of health training assessment in developing countries such an undertaking faces a number of difficulties concerning the problems inherent to assessment, the particular and unstable nature of the environment, and the problems associated with humanitarian action and development aid. It is difficult to choose between a formal and a natural approach. Indeed, a dual approach, combining quantitative and qualitative data, seems best suited to a variety of cultural contexts of variable stability. Faced with these difficulties, a criteria-based, formative, quality-oriented assessment aimed at improving teaching and learning methods should be able to satisfy the needs of training professionals [18].

Regarding the results of the subjects, they indicate a high performance by the students, who also value positively the usefulness of the subjects and the coherence of the evaluation systems. The performance, efficiency, and success rates in the subjects are very high, and the satisfaction of the students is very important in two very important areas: the teaching quality of the professors and the facilities and infrastructures for training and carrying out external practices. All the good results are reflected externally with the awarding of the prizes in 2019 for the best postgraduate study and the best TFM defended in gender violence.

Another question is that professionals carry out their humanitarian action work in the field is related to transparency in the aid impact assessment and evaluation: this requires serious thought because who is evaluated? Who evaluates? And how is it evaluated? In principle, organizations are evaluated by partners, not by beneficiaries, who are usually the poorest sectors of the population (war victims, refugees, etc.), people who are not satisfied with their conditions and may not agree with the help received, as well that then, can the evaluators ignore the opinion of those who receive help? [19].

As for who evaluates, many times they are specialists who try to develop general rules theoretically according to Western standards, not adapted to local contexts. Some organizations, since those organizations with bad practices, avoid being evaluated because they have something to hide. Obviously, it is more difficult to hide bad practices when working in democratic contexts [20].

In addition, everyone is interested in positive reviews of their activities. The aid agencies, for their image of efficiency, help a lot in recruitment campaigns of funds. Governments of donor countries because this allows them to validate the approval of their projects. Evaluators for their self-evaluations. Some authors comment that when asking the aid workers themselves, it is not easy to get information on these issues; they are professionals and all know each other. Volunteers are afraid of reprisals or losing their jobs. If aid recipients are asked questions related to the corruption or misappropriation of funds, they speak little because of the discontinuation of programs, and if you ask aid funders because they do not want to hear talk too much about the failures of the programs they fund [21, 22].

Regarding how it is evaluated, the different professionals comment that the indicators of the evaluation forms are complex and do not capture all needs, so the organizations prefer to work with statistical data, which do not reflect the social impact of the help. Aid organizations usually promote qualitative analysis that pleases donors to insist on successes, hide failures, and exaggerate positive impacts on poverty [23].

Many issues still need to be improved but also many lessons learned. And perhaps, as always, the most important thing is the prevention mechanisms. so some authors propose to follow a series of steps that “a priori” seem interesting due to their simplicity in the prevention of these conflicts: (i) a public consultation, capable of identifying the needs of the population and what can be done at the governmental level or from the local administration of a country, (ii) a decision-making process based on the above reasons. In this sense, the author proposes the figure of an “ombudsman” capable of arbitrating and making final decisions, (iii) publicizing decisions, (iv) a constant review while working in the field and after completing the project, and (v) surveillance through regulatory systems that ensure that all conditions are respected [24]. For an appropriate evaluation, specific and quality training is needed.

In this sense, professional quality training in different skills related to the complex world of humanitarian action will position governmental and non-governmental agencies in the best possible scenario to cover a quality action. This is our greatest wish.

2. Conclusion

Humanitarian crises represent a significant public health risk factor for affected populations, exacerbating mortality, morbidity, and disabilities and reducing access to and quality of health care. The international humanitarian community, in responding to international calls for improved accountability, transparency, coordination, and a registry of professionalized international responders, has recently launched a call for further professionalization within the humanitarian assistance sector, especially among academic-affiliated education and training programs. So, in line with other authors, we argue for the professionalization of disaster medicine and public health as an essential discipline in support of global public health security, and we proposed a Master. The professionalization movement endorses a standard route to certification through the completion of a competency-based curriculum, demonstrating competency through examination or experience to produce learning. These programs devise certification criteria for entry, mid-level, and higher-level candidates who serve in domestic and global humanitarian crises. The development of a core curriculum that sets the basis for knowledge and capabilities is required by the increasingly complicated humanitarian world.

Conflict of interest

The authors declare no conflict of interest.