Problem
 
Should Short-term healthcare mission team members obtain licenses to practice within a host country?
 
Consider the following report.
A local doctor arrested this month in Zimbabwe on charges of practicing without a license during a mission trip was released this week, say officials. Dr. Ed Montgomery and his wife, Sara Jane, a nurse, have both been given back their passports, confirmed Senator Mitch McConnell's office Tuesday. The pair had been relieved of their passports approximately two weeks ago while on a medical mission trip in the African country. According to his friends, Dr. Montgomery had been looking forward to the trip with friends. A retired urologist, Dr. Montgomery and his wife had participated in several other medical missions around the world.
 
According to Dr. Montgomery's former partner, Dr. Scott Scutchfield, after Dr. Montgomery's charges were dropped he headed with his wife to South Africa.
 
Julie Adams, deputy press secretary for McConnell's office, said the doctor had worked with the embassy and Zimbabwe officials to obtain a license to practice in that country and hence the charges were dropped. It was definitely a happy ending, said Adams. For the friends and family waiting at home for the Montgomerys, the couple's release comes after days of prayer and concern. "I'm thankful to God," said Scutchfield, after many prayers and well wishes were sent their way from the medical community. "Everyone will be relieved.” Family friend Dr. Chris Jackson also applauded the good news, and those who had helped to bring it about. "We're very pleased for all the efforts made for us," said Jackson, including the help of the newspapers and politicians. The recent news was "wonderful," said Jackson. "I can't wait to get him home." (BURTON, 2004)
 
We might also consider how we, as healthcare professionals in the United States would respond if we were to reverse the situation.  How would we respond if a group of doctors and nurses from Myanmar came to the United States and started holding medical clinics at a local church? 
 
Research
 
Health Professional Regulatory Agencies
 
One of the central tenants held by the patient in the healer-patient relationship is that the healer is skilled and trustworthy. In developed countries there is an increased emphasis on licensing and competency assessment so that the patient can be assured that a healer has at least the basic knowledge needed to successfully manage health-related problems.  End of training examinations, board and sub-board examinations have long been a standard to assess competency. Boards act to screen-out individuals who need to study more or may be poorly suited for medicine. (Hechel, 1979)
 
Nursing, Psychology, Dental and Medical Boards regulate professional licenses. In some countries, like the United States, the regulatory bodies function at the state/province level making it such that a healthcare professional’s license is only valid in the state in which it was issued. Professional boards not only provide the initial license, but ensure that a practitioner participates in continuing education on a yearly basis. Demonstrating one’s current license to an employer is the only means by which one will be allowed access to provide care in a hospital or clinic setting. Without the license the individual cannot be employed in the United States. (Johnson, 2005)
 
Care provided by medical missions must meet the legal requirements and medical standards and practice guidelines of the host country. Until relatively recently, very few standards and guidelines were available, and those were rarely enforced. Over the past several years, numerous standards and guidelines have been established for the care of patients in developing countries.  Just as in the U.S.A. where harsh penalties exist for practicing medicine without proper permission, developing countries are beginning to enforce licensure requirements.
 
Solution
 
Country/State Specific Requirements for Practice
 
So we are increasingly asked: “How and where do I apply for a license or legal permission to practice in _______?”  Until relatively recently this question was very difficult to answer, as just as in the U.S.A., the contact information and licensing requirements are often different for different states or regions within the same country.
 
Fortunately for medical professionals, this information is now provided by the International Association of Medical Regulatory Authorities (IAMRA), www.iamra.com.  This site provides very important contact information for obtaining licensing/legal permission to practice medicine in host countries.  The site includes an “International Directory of Medical Regulatory Authorities” to assist medical regulatory authorities in the exchange of important physician information. The directory provides core information for all known medical regulatory authorities, such as addresses and communication sites/portals, as well a brief description of the legal authority by which the organization received its regulatory powers and the regulatory services provided by the organization
 
For nursing, the International Council of Nurses, www.icn.ch, maintains a list of nursing councils and their contact information.  Contacting the nursing council for the host country will help begin the process of obtaining a license.  Nurses going on short term trips can often be given a temporary license.  For nurses who seek to practice longer term in country, there may be additional education and practice requirements, such as midwifery, that are not included in basic nursing education in the US.  Expatriate nurses wishing to practice nursing in the US are required to demonstrate that they have graduated from an approved nursing program and met the licensure requirements of the country of origin, or pass the NCLEX examination in the US. (Mc Dougal, October 2011)  Likewise US nurses going abroad should respect their host country’s nursing authorities.
 
Case in point
 
Arriving in Uganda in 1985, during the middle of the civil war, neither my sending organization nor my host organization encouraged me to pursue getting a nursing license to practice.  Our community health development work operated in close cooperation with the district health office.  I was told by the district medical officer that a license was not required.  Still I persisted.  I learned where the nursing council who regulated nursing practice was located in the capital city of Kampala.  On my next trip to the capital, I went there with my documents.  The director looked at my documents and thanked me for pursuing a nursing license.  She said that not many expatriates respected the efforts of the Ugandan nursing council to regulate nursing practice and that enforcing their regulations on expatriates was difficult, especially during the war.  Then she confessed that she really didn’t have a reference for how to evaluate American nursing education and licensure.  Having been involved in nursing education in the US, I explained the various nursing education programs that led to professional licensure.  She was so grateful and gave me my license. 
 
Later, when the war had ended, I received an invitation to work with the Ministry of Health in Uganda to revise the nursing curriculum and again several years later to work with them to begin the first baccalaureate nursing program in East Africa.  If I had not pursued getting a nursing license, I would never have been offered the opportunity to come along side of the Ugandan nursing leaders to advance nursing education in my host country.
 
Conclusion
 
Recommendations.
 
1.  The BEST practice is to obtain appropriate licensing in the host country for each team member. Although time consuming, it places the team on a firm footing within the country
 
Given the coordination requirements, it would be best if the team leader(s) and the Church/sending organization take initial responsibility for this task.  It is important to discuss this issue with the in-country partner early so they can communicate with the host governing authorities regarding visiting healthcare teams.  Healthcare professionals going on the short term missions projects should be ready to submit their credentials – educational transcripts and/or licenses to practice – to the sending organization and/or in country partner or host governing authority.  
 
If the in-country partner is not engaged professionally in providing healthcare, it is inappropriate to assume that they will be knowledgeable about licensing issues for expatriates or that they will automatically take responsibility for obtaining licensing/permission to practice.  For example, groups that partner with churches, orphanages, or economic development programs in host countries, should discuss with their host organizations the importance of getting permission for visiting teams to practice their professions while in country.
 
2.  A BETTER practice when the healthcare professional is unable to obtain official licensing is to obtain approval through local authorities who are in a position to approve team practice. 
 
Some partners, particularly in creative access countries, may indicate that obtaining licenses brings greater scrutiny to their work/organization than they would like. They may have local governmental contacts that provide coverage should there be any questions or problems. In these cases, the healthcare professional and the sending organization must assess the risk to both themselves and the host organization.  It is also important to factor into the equation relationships between the sender and receiving countries. Governments may express their displeasure by detaining or expelling missionaries, even medical mission teams to make a political point.
 
3.  A GOOD practice is to proceed with caution in countries where there is no stable government or health ministry/licensing organ.  Some team leaders would rather go without licenses, thinking that should there be a problem, they can plead ignorance and ask for forgiveness. This strategy is very risky and can lead to problems.
 
Consequences of not becoming licensed.
 
There can be significant amount of fall out for the people served, churches, participating local doctors, partners and governmental officials in-country.  For the people served, the exposure of the team’s lack of licensing may lead to concerns about the adequacy of their care. They may even wonder if their participation in such a situation may negatively impact them.  Churches can be negatively impacted by the perception of wrong-doing by short-term healthcare mission team.  For the participating local doctors, the disclosure that their short-term mission team partners have not followed the law, can create a perception of loss of reputation within the community.  Trust in the mission partner can be negatively impacted.
 
For partners, the disclosure that their short-term mission team partners have not followed the law can cause profound problems. From the government’s perspective, the partner is primarily responsible for the short-term mission team. Licensing for the partnership organization may be lost or even missionaries may be imprisoned or deported.
 
For the governmental officials, the disclosure that their short-term mission team has not followed the law, creates a question of who is responsible. If a mission partner is responsible, then prosecution of the mission partner is a possible route. If a governmental official is thought to be responsible, then they are at risk of losing credibility or even their position. For this reason, local governmental officials may be skittish about approving mission team visits. There can be a perception that there is more to lose than to gain unless the mission partner has a very strong relationship with the governmental official.
 
The major impact of problems related to no in-country licensing is a lack of trust that can destroy relationships.

Works Cited

BURTON, E. (2004, July 21). Dr. Montgomery released in Zimbabwe, charges dropped. Retrieved from The Zimbabwe Situation: http://www.zimbabwesituation.com/jul22_2004.html#link8
Hechel, H. &. (1979). Specialty certification in North America: a compartive analysis of examination results. Journal of Medical Education, 69-74.
Johnson, D. A. (2005). Role of state medical boards in continuing medical education. Journal of Continuing Education in the Health Professions, 183-9.
Mc Dougal, B. e. (October 2011). The 2011 Uniform Licensure Requirements for Adoption. Journal of Nursing Regulation, 10-22.