BROCHER DECLARATION

We, the undersigned, call on the international community to make every effort to maximize the value and minimize the harm of short-term engagements in global health. We urge health professionals, educators, faith-based organizations, non-governmental organizations, and other
entities that participate in these short-term engagements to do so with awareness of the challenges and concerns, with due respect to all concerned, 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 health and wellbeing around the world.
• 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 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 at times unintentionally causing more harm than good. It is crucial for visitors from high income countries to shift the paradigm from viewing host communities as the “other” to viewing themselves as “outsiders”, while acknowledging the differences in needs, culture, and practices. 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 varies greatly in terms of diseases, cultural and social determinants of health, languages spoken, clinical protocols, as well as political and economic conditions. This often leads to misalignment of short-term global health activities with the host country workforce and health priorities. Global health engagement should emphasize mutual partnership and bidirectionality, recognizing the expertise and experience of host country health professionals.
2. Empowered host country and community define needs and activities
   When short-term global health engagements are based on perceived needs or available skills, they can undermine the local voice while diverting much needed funds and efforts away from real needs, along with placing added burden of accommodation and safety on host communities. 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 needs 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 host country. 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 and legal requirements.
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 limitations of the communities they are visiting, while simultaneously recognizing the limitations of their cursory understanding as non-members 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 negative impacts, they should be altered or ended. There should be special emphasis placed on the concerns of environmental impact due to the travel and activities involved.

We call for efforts towards the ethical conduct of short-term global health engagements. Such activities are currently largely 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 shortterm 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 implementation of the principles outlined above, we hope to improve global health work and most importantly, the impacts of that work on host communities.